Chapter 1: Introduction to 21st-century psychotherapies
Historical foundations of psychotherapy
Since the beginning of humankind man always sought means to remedy the mental
disorders that have afflicted them. Some remedies could’ve been unscientific, but that
doesn’t mean that they were ineffective (think about meditation or religious rituals). The
Hellenist physicians (time of Hippocrates) see the brain as a set of knowledge and
learning, but at the same time as a source of depression, delirium and madness. Until
the 18th century there was no such thing as the science of psychotherapy
The unconscious
A primordial construct
In many theories the unconscious plays a central role. During the 19th century a lot of
psychotherapies emerged which all centered around the unconscious. The first scientific
study of the unconscious was done by Wilhelm Leibniz, he studied the role of subliminal
perceptions in our daily life. He also was the to describe the forces in our unconscious
as dynamic.
Furthermore, Johann Friedrich Herbart attempted to describe the passage of memories
to and from the conscious and the unconscious. So called tactic ideas battle with one
another for access to the consciousness. When an idea is associated with another idea
the chance is big that this idea is also drawn into consciousness.
Mesmer and Schopenhauer
These guys are the most influential and creative thinkers during the early 19th century.
Mesmer was a pioneer in hypnotherapy. This kind of therapy was the first new therapy
since exorcism, but it also had a lot of unsubstantiated hypotheses. In his hypnotherapy
he mentioned that the unconscious is the key factor of shaping behavior in general. As
you might know when you see the lectures it was important that the client believed in
the treatment, otherwise it would not work. His theory was dependent on believing and
openness to experience.
Schopenhauer claimed that the world can be seen as ‘will’ and ‘idea’. He said that we
know thing that we are unaware of and that we are largely driven by blind, irrational
forces.
Psychotherapy-related science in the 19th century
The natural science empiricists
Fechner and Helmholtz conducted seminal research in the area of cognitive science and
they are seen as key players in this field. Fechner stressed the difference between waking
and sleeping states (with a lot of attention toward the dream state). He also claimed that
he unconscious exists and tried to measure the amount of stimulation needed for ideas
to cross the threshold of unconscious to conscious (this is now seen as the working
memory). Helmholtz discovered the phenomenon of unconscious inference, which he
explained as following: a kind of instantaneous and unconscious reconstruction of what
our past taught us about the object.
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,The clinician-researchers
A worthy name to mention is Benedict, he developed the concept of seeking out and
clinically purging pathogenic secrets, which is later an essential part in the analytic
psychotherapy.
Psychotherapies are in constant evolution, but clinicians often continue to use the
strategies, techniques and other thing they learned in their graduate programs. Keep in
mind that these theories might be outdated!
Impact of the biological sciences on psychotherapy
According to research when a patients learns about a new idea he or she also alters part
of his brain. The biological claim is that every encounter with our environment causes
certain changes in us and in our neural functioning. This means that when you learned
a specific skill completely it is set in our brain, and difficult to unlearn (so education =
permanent). According to biology the task of the therapist is to help the patient adopt
new motivational schemas, so that they can have alternative memories in the future.
Grawe stated that psychotherapy works, because its changes gene expressions at the
neuronal level of the brain. Further neuronal embedding of patients in their
dysfunctional past can be done by prodding them to ruminate about that past, but this
does not eras their painful memories nor their dwelling on those memories. Furthermore
he claimed that an effective therapist teaches parents how to avoid dysfunctional
ruminations, harmful behavioral routines, and maladaptive habits. This will allow them
to advance their wellbeing and that of others around them.
A lot of these theories have one key concept in common: epigenetic change. Epigenetic
change states that external events can turn genes off or on and change the genome in a
cell. So minor external events can have an enormous impact on the way a client
perceives and experiences himself.
Cultural factors and psychotherapy
Multicultural psychotherapy
There are great complexities involved when there is a cultural difference during
counseling. It matter a lot if the therapist is a member of a minority, non-dominant or
dominant culture. This problem becomes even bigger when a biracial couple is seeking
for counseling, because the therapist can unknowingly identify himself with one spouse.
Language and metaphor
Of course there is also a barrier in languages, behavioral mannerism, local and national
poetry, and metaphors in different cultures. This could lead to problems in counseling
when both parties don’t understand what is meant. Keep in mind that this kind of
mannerism can also be local in stead of cross-national.
Negotiating fault lines in the brain
Psychotherapy: an art or a science
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,At the moment there is still a big search for empirically based treatment, so that there is
a way to demonstrate the scientific validity of that therapy. But this is hard for many
different reasons. One of the biggest reasons is that therapists usually only work with
patients once a week, while the rest of the week these clients are exposed to
contingencies outside of the session. These random “outside of therapy” events are
called context dependent stochastologicals.
Concludingly, it’s really hard to prove a treatment as empirically based, because clients
are exposed to way more than just the therapy.
Manualization of treatment
Spontaneous, unplanned throw-ins (a verbal intervention that acknowledges something)
are hardly a basis for science of psychotherapy, but they can have a lot of impact on a
client.
Source of hope
Almost all therapists rely to some degree on intuitive inspiration and creative
imagination in deciding what to do next in a session. Where some therapies are
amenable to manualization than others, they should not be preferred for this reason.
Therapies require adjustment and compromise, where therapeutic judgement and
creativity plays a big role.
Conclusion
According to Cosini (writer of the book) one should choose to develop expertise in a
therapeutic approach that suit one’s personality. However, there are some issues with
this. For example there are some disorders that are treated best by a specific treatment
or certain therapists achieve more clinical success when they treat one specific disorder.
This means that the select of a domain might limit the competence of a therapist.
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,Chapter 2: Psychoanalytic Psychotherapies
Psychoanalysis (PA) is a distinctive form of psychological treatment and a model of
psychological functioning, human development and psychopathology. Freud is seen as
the father of psychoanalysis, but keep in mind that it differs in some ways if it’s
compared to the Freudian theory. The basic principles of psychoanalysis are:
- An assumption that all human being are motivated in part by wishes, fantasies, or
tactic knowledge that is outside of awareness (unconscious motivation)
- An interest in facilitating awareness of unconscious motivations, thereby increasing
choice
- An emphasis on exploring the ways in which we avoid painful or threatening
feelings, fantasies, and thoughts
- An assumption that we are ambivalent about changing and an emphasis on the
importance of exploring this ambivalence
- An emphasis on using the therapeutic relationship as an arena for exploring client’s
self-defeating processes and actions
- An emphasis on helping clients to understand the way in which their own
constriction of their past and present plays a role in perpetuating their self-defeating
patterns.
Basic concepts of psychoanalysis
The unconscious
One of the key concepts of Freud’s insights is that we are not masters of our own houses.
This means that our rational understanding of the factors that motivate our actions are
often inadequate. Freud saw the unconscious as an area of psychic function in which
impulses, whishes, and certain memories are split off from awareness. The stated that
the reason for this might be that the associated effects are too threatening or
unacceptable through cultural conditioning.
Nowadays the term unconscious is not the same as in Freud’s time. People argue that it
is better to conceptualize any experience or action as reflecting a particular type of
compromise between an underlying wish vs. a fear of the consequences achieving it.
Others state that the unconscious is the dissociation of experience, because attention and
narrative construction failure. But all these theories have in common that our
experiences and actions are influenced by psychological processes that are not part of
our conscious awareness. And these unconscious processes are kept out of awareness in
order to avoid a certain type of psychological pain.
Fantasy
In Freud’s psychoanalytical theory fantasy plays a big role. Fantasies are seen as the
motivator of our behavior and it shapes how we experience things. Think about things
that Freud said regarding sexual or aggression fantasies. He later changed into thinking
that fantasies served a number of psychic functioning, such as regulation of self-esteem,
need for safety, and need for regulating affect. Exploring and interpreting client’s
fantasies are an important part of the psychoanalytic process.
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,Primary and secondary processes
Primary processes are a raw or primitive form of psychic functioning that begins at
birth and continues to operate unconsciously throughout lifetime. It does not make a
distinction between the past, present, and future. Different feelings and experiences are
condensed together into one image or symbol and those feelings can be expressed
metaphorically. In contrary, secondary processes are associated with the conscious
mind. These processes are logical, sequential (time dependent), and orderly. The
foundation of these processes are rational and reflective thinking.
Defenses
A defense is an intra-psychic process that functions to avoid a certain emotional pain
by pushing thoughts, whishes, feelings, or fantasies out of awareness. According to the
psychoanalytical theory of Freud there are a few different defense mechanisms:
- Intellectualization: the individual talks about something threatening while keeping
an emotional distance from the feelings that are associated with it.
- Projection: the individual attributes the threatening feeling to another person.
- Reaction formation: the individual denies a threatening feeling an proclaims that
he feels the opposite.
- Splitting: an Kleinian theory which states that an individual attempts to avoid his or
her perception of an other person as bad, by splitting the person into two different
persons. One is the bad person and one is the good person. This can be seen in infants
and they use it as a strategy to feel safe with their mothers.
Transference
Transference is when a client sees the therapists in such a way that they did to their
own significant figure of their childhood. It basically means that the client transfers a
certain template/scheme of a significant figure onto the present situation. Transference
is seen as an important part of treatment, while reliving the past helps understanding
certain feelings or behaviors.
One vs. two person psychologies
There has been a shift in the way psychology has to be done. Therapists and clients are
now seen as co-participants who engage in an ongoing process of mutual influence at
both conscious and unconscious levels. This implies that the therapist is unable to
develop an accurate understanding of the client without developing some awareness of
his own ongoing contribution to the interaction (think about transference and
countertransference!). The 2-person psychology emphasizes that the therapist often
plays and important role in the creation of resistance in the client.
Other systems and psychoanalysis
Psychoanalysis is the first modern western system of psychotherapy, many other
theories evolved out of it or as a reaction towards it. It’s not just a form of therapy, but
it can be seen as a worldview or paradigm.
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,Nowadays psychoanalysis declines in popularity, because there is a growing emphasis
on biological and evidence bases treatments. Therapists who did complete
psychoanalysis training were seen as the elite withing psychology, which meant that it
became a lucrative and prestigious profession.
Criticism towards psychoanalysis is mainly about the fact that it underestimates the
complex human nature and difficulty of change in their processes.
History
Freud’s development of psychoanalysis was influenced by many different trends of that
time. There was a formative influence, mainly by Jean-Martin Charchot. He was a
French neurology and psychiatric that talked a lot about the splitting of consciousness.
He also did a lot of hypnosis on hysterics ( a client who presented a variety of dramatic
physical problems that could not be accounted for by an organic basis, which in the time
were mainly woman). Charcot claimed that these symptoms emerged as a result of
splitting off aspects of consciousness as a result of organic weakness, according to him
the way to tackle this problem was hypnosis.
Another influence was Josef Breuer, he was a man that treated female patients with
severe hysteria symptoms. His technique involved experimenting with different
therapeutic approaches and modifying these approaches according to the client’s
responses (or feedback). His assumption was that the symptoms of hysteria were of
psychological basis. Treatment according to him was done by talking about painful and
traumatic experiences in order to relief the symptoms.
Both Breuer and Freud came to belief that symptoms were the results of suppressed
emotions that had been cut off at the time of the trauma. These suppressed emotions
expressed themselves in the form of physical symptom. To get to these suppressed
emotions one has to perform hypnosis. They were the first to claim that hysteria wasn’t
a organic, but an psychological originated disorder
Beginning
Over time Freud found hypnosis unreliable, because some patients were not suggestible
enough to respond to it. At this moment he began to encourage patients to say everything
that comes in mind without censoring their thoughts, this was later named the free
association technique. By this time his psychoanalytic theory wasn’t relying on
hypnosis anymore.
From seduction to drive theory
The seduction theory claims that the root of every psychological problem is a sexual
trauma. Where there was a lot of emphasis on the role of fantasy and instinctual sexual
drives. This also theorized that rudimentary sexual feelings are present even during early
infancy and give rise to sexually related wishes and fantasies, which are pushed out of
consciousness because they are experienced as too threatening.
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,The drive theory claims that the physic energy (also called libido) could be activated
by both external and internal stimuli. This activation could produce a feeling of tension
or unpleasure. Maintaining this energy at equilibrium was needed, thus once energy
becomes activated it needed to be discharged which resulted into the experience of
pleasure. When one repeats experiences that have become associated with tension
reduction, people call it the pleasure principle.
Jung, Bleuler, and the psychoanalytic society
There was a growing interest in Freud’s work by Bleuler, he was a promintent swiss
psychiatrist and he was interested in the use of methods borrowed from experimental
psychology. He hired Jung to investigate the response times latencies to emotionally
charged words. They intertwined the idea of Freud’s unconsciousness with the results
and stated that there were emotional complexes. These complexes are affectively
charged ideas that are repressed, because they are emotionally threating.
The development of structural theory and the Ego psychology
In 1923 Freud came up with the structural theory, in this theory he explained that id,
ego and superego interact to deal with the demands of reality and the pleasure principle.
Where the pleasure principle can be seen as ‘id’, the ego can be seen as a referee between
id and superego, and the superego can be seen as the moral compass, including all values
and norms of society.
The development of object relation theory in Britain
The object relations theory looks into the way in which we develop internal
representations of our relationship with significant others. A key player in this field is
Klein, he tried to understand the early relationship between mother and infant. And he
concluded that psychological maturation is reached by processes of developing internal
representations of our relationships with significant others.
Current status of psychoanalysis
Nowadays psychoanalytic is still the main player in Northern America psychologic (on
the contrary, in Europe there are competing theories such as the one from Klein). The
goal according to them is that a client should get more insight into his own unconscious
conflicts. This can be reached when the therapist projects himself as a blank screen for
reflection.
The interpersonal psychoanalysis of Sullivan theorized that the need form human
relatedness is the most fundamental human motivation and so he de-privileged the
motivational role of sexuality.
The relational psychoanalysis of Mitchell rejects the drive theory and placed a greater
emphasis on instinctual need for human relatedness. He also claimed that it’s impossible
for a therapist to work as a blank screen, while everyone is subjective in a certain way.
According to him the therapeutic relationship is a crucial ingredient to success.
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,The modern conflict theory emerged out of ego psychology and it emphasizes the
centrality in human experience and the action of ongoing conflict between unconscious
wishes and defenses.
Lacanian traditions in Europe and Latin America
Lacan was a man who was critical toward the American ego psychology. He viewed
ego psychology as emphasizing conventionality and societal conformity. With this he
argued that the ego is merely an illusion. The identity or sense of “I”-ness is forged out
of misidentification of ourselves with the desire of the other.
Lacan does not belief that there is a true self that has to be discovered, but the reason
why people experiencing symptoms is because there is a feeling of emptiness (which is
a fundamental sense for alienation from the self). This lack or emptiness stems part from
the fact that our experience can not be communicated without language. The process of
expressing our experiences through languages results into a distortion of this experience.
Personality according to psychoanalytic
Conflict theory
The intra-physic conflict has been viewed as a central role into developing a specific
personality. Different personalities can be understood as resulting form the comprises
between specific underlying core wishes and characteristic styles of defense that are
used to manage these wishes. According to this theory there are 4 different kind of styles
an individual can have:
- Obsessional style: conflict between obedience and defiance, intellectualization as
key defines to manage underlying emotions
- Hysterical style: underlying wish for emotional intimacy that is defended by
superficial or dramatic emotionality or seductiveness.
- Phobic style: displacing intra-psychic conflicts onto external situations. Conflicts
around sexual feelings are defended by displacing anxiety onto public situations
- Narcissistic style: defending against underlying wishes for dependency and fear of
abandonment. This is done by surface feelings of grandiosity and self-aggrandizing
behavior.
Object relation theory
The object relations perspective on personality theories that internal representations /
object / object relations influence the way in which people perceive others, choose
relationships with certain people, and shape their relationship accordingly. Think about
the theory of attachment by Bowlby.
Furthermore, the object relation theory assumes that internal models (representation of
interactions with an attachment figure that allows a person to predict what type of
actions will increase the possibility of maintain proximity) are shaped by a combination
of real experiences with unconscious wishes and fantasies which are not reality based.
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,According to Klein people are born with instinctual passions related to both love and
aggression. These are linked to unconscious fantasies and images about relationships
with others. He claims that instinctual aggression plays an important role in this. Infants
experience aggression as intolerable and thus fantasies that the aggression originates in
the other person (projective identification). The infant unconsciously splits the image
of the other into good and bad aspects so it can remain proximity. When an infant
matures these two aspects are merged into one.
But this theory lacks systematic consistency and is hard to grasp to.
Developmental arrest models
Self-psychology claims that the psychological problem emerges as a result of the failure
of caregivers to provide a “good-enough” or optimal environment, which means that the
normal development becomes arrested. Infants begin in a state of subjective
omnipotence, which means that they believe his or her wishes make thing happen and
that the mother will do everything to satisfy those needs. But over time it is inevitable
that the mother will fail to meet the needs, then the infants learns the distinction between
reality and fantasy.
Psychotherapy
Theory of psychotherapy
What is psychoanalytic thought?
Traditionally psychoanalysis have made a clear distinction between psychoanalysis vs.
psychoanalytic / psychodynamic theory. While psychoanalysis is a term for a form of
treatment with defining characteristics, the psychodynamic theory is a term to refer of
forms of treatments that are based on the psychoanalytic theory but lack some of the
defining characteristics of psychoanalysis.
These defining characteristics of psychoanalysis are:
- Long term and open ended
- Intensive
- Therapeutic stance
But nowadays people don’t make these kind of distinctions anymore, it’s a more
pluralistic perspective
The therapeutic alliance
The therapeutic alliance originated in early psychoanalytic theory. Freud emphasized
the importance of establishing a good collaborative relationship with the client.
Transference and countertransference
Transference refers to the client’s tendency to view the therapists in terms that are
shape by his or her own experience with significant others. The theory behind this is
that early life experiences establish templates or schemas that shape the perception of
people in the present. Therapists use this knowledge to gain insight in these kind of
memories or experiences.
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, Countertransference is the therapist’s counterpart of the client’s transference. The
feelings and reactions toward the client’s transference are functions of his own
unresolved conflicts. Freud claimed that this was an obstacle during therapy. It can be a
valuable source of information for the therapist if he looks to the totally of the
interactions between transference and countertransference (also: transference-
countertransference matrix).
Resistance
The term resistance refers to the tendency of an individual to resist change or actin in
such a way that it undermines the therapeutic process. Reasons for resistance might be
that it’s a form of defense. It might be problematic or helpful, depending on the reason
why the client is resisting. While it can either be an intrinsic mode of the client’s
functioning or as a problem in the therapy.
Intersubjectivity
The analytic dyad is the meeting of two mind in therapy that produces a new, emergent
product. It’s an understanding in psychotherapy that derives out of the dialogue. This
process of intersubjective negotiation allows the client to gradually learn that human
relationships are flexible and that it’s possible to recognize the potential validation of
the other’s perspective without feeling demolished or invalidated.
The process of transference and the therapist accepting or rejecting the transference
plays an important role in helping the client to develop the capacity of intersubjectivity
(the ability to hold onto one’s own experience while at the same time beginning to
experience the other as an independent center of subjectivity.
Enactment
Enactment has become a key concept in contemporary psychoanalytic thinking. Clients
and therapists are always influencing each other at a conscious and unconscious level.
In the end that means that they will play complementary roles in relational scenarios of
which neither is fully aware. When these scenarios are explored it can provide the client
with an opportunity to see how their own relational schemas contribute to the enactment.
Process of psychotherapy
Empathy
Empathy is the ability to identify with a client and immerse ourselves in their
experience, which is a critical process of establishing a therapeutic alliance. According
to Kohut, empathy helps clients to make sense of their own experiences and will-timed
questions can serer as clarifying.
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