Interpersonal/Relational PsychoanalyticTheories

PSYC E-2488 Lecture #4-#5

10/22 & 29/07

Historical Background

• Relational 1. Miller & Stiver (1997):

– Female Study Group at McLean (included training/junior staff with extensive multi-theoretical background and familiarity with Vippassana Buddhism)

– Feminist Zeitgeist: Reaction to the unexamined and implicit pathologizing of female characteristics in culturally imbedded values (mother is responsible, separation/individuation is positive goal of development) – Deconstruction an important concept

– Women’s experience suppressed to avoid disrupting culture (+/-)– Medical School and Academic Setting steeped in academic/BPSI

psychoanalytic orientation- Limited understanding of women and their relational context

thinking – seen as morally inferior by some (for the relationship, not instrumental & power-oriented,definition of greatest good is different).

Class Exercise – Drawing the Linesand Defining the Boundaries

- 20 minutes -• The Beatnik says, ”Cool, Man”; the Hippie, “Wow, far

out”; the Psychotic Patient, “I am God”, the Zen Monk has an experience of kensho, the Psychologist calls it “Flow”, the Jazz Musician grooves, and the Therapist says, “Hmmm”.

All can be understood as experiencing a dissolution of self-other boundaries and a re-immersion in a reality that has shifted significantly. Interpersonal-Relational therapeutic frameworks seek to define and practice their craft and art by how they make this space therapeutic. How do you sort out who the Self/Other is and the Relationship between them?

Historical Background – con’d.

2. Curtis & Hirsch, 2003)

a. H.S.Sullivan & the Americans

- Derived from work with schizophrenic and severely character disordered patients (Chestnut Lodge)

- Influenced by cultural anthropologists

b. English (Fairbairn, Winnicott, Klein)

Historical Background con’d.• 3. Malan (2001): “The 2 Triangles” & “Koch’s Postulates” in Psychodynamics - p.90-91 – Goes beyond rapport to transference (Freud and the 2nd Triangle noted by

Karl Menninger, 1958 The Theory of Psychoanalytic Technique) a. T1 – triangle of conflict (Defence, Anxiety, Hidden Feeling) and T2 – triangle of

person (Other, Transference, Parent or Sibling) b. Each T stands on an apex (because 1 of the 3 elements lies underneath the other 2) - 3 possible links (O/P – feelings toward other are from P/S; O/T – feelings are similar

feelings directed toward Other and Therapist; T/P – Transference links are derived from feelings about Parent or Siblings) c. #1 – Patient’s genetic events + precip[itants suggest the nature of the conflict

underlying the symptoms; #2 – A detailed mechanism can be formulated whereby symptom represents the conflict symbolically; #3 – Interpretation of the mechanism to patient raises level of consciousness; #4 NB – Consequently symptom disappears.

• Differences between relational theories: - Not clear they are the same in core concepts and ideals?

The Concept of Personality1. Miller & Stiver (1997) - Feminine Trait: “…active participation in the development of others.”; - “…relationships are the means to the development of a separate self.”(p.22); - Ideal is to foster everyone’s development. - All relationships can be the source of reconnection. - Connection (defined): Mutually empathic and mutually empowering (e.g., adds

“…‘zest’, action, knowledge, worth, and desire for more connection”)”…replaced self as the core element or locus of energy in development.” (Surrey)

- From very early age people want and need connection with others - Inner relational images are the framework by which we guide our actions and order

our experience. People can have multiple ones, including idealizations. - Individual’s solutions may perpetuate disconnections, by creating a central relational

paradox, in which the person keeps significant parts of themselves out of connections and thus subverts a healthy process.

- Unconscious: The repository of unconscious memories, relational images, and split off parts of the patient that begin to emerge in the safety of the therapeutic relationship; and, which on examination and exploration gives rise to the emergence of more unconscious and painful material.

Concept of Personality con’d.

2. Curtis & Hitsch (2003):

- Not a unified concept, but a “stable pattern of being in the world”;

- Current relational pattern is an update of earlier ones;

Psychological Health and Pathology

1. M&S (1997):Connection (PT-enmeshment) vs. Disconnection (PT-separation/individuation)

- Notice the implicit values and need for definitions - Dysfunction particularly evident in power relationships; - Disconnection is the source of psychological problems; defined as “…psychological

experience of rupture that occurs whenever a (person) is prevented from participating in a mutually empathic and mutually empowering interaction.” p. 65.- Minor disconnections frequent and can be resolved when subject or others take action to make disconnection known.- Major disconnections can result in a mixed ms. of emotions, lack of clarity, a sense of responsibility for the experience and then projection of unpleasant feelings (most powerful impact on kids). Can feel condemned to isolation and powerlessness. Can try to change self (since can’t change others) with result in cut off from self, inauthentic relations with others, dysphoric affects and apprehension about relationships. Future is guided by -, not + expectations.- “Power-over” relationships (patriarchal and socially defined us and them based on race, class, gender, sexual orientation) create disconnections;- Non-mutual relationships lie on a continuum from lack of awareness of the other to violation of the other.

Psychological Health and Pathology con’d.

- Disconnections in Families are Due to:* Secrecy* Inaccessibility of Parents* Parentification

Result – Can create and perpetuate disconnections due to impact on children’s needs, access to experience and mutual relationships,

with result that world is seen as dangerous and unrewarding. - Disconnections as a Strategy for Survival:

* Forms of Emotional Disengagement (e.g., pre-occupation, dissociation, substance abuse, in-attention);

* Role-playing (inauthentic) * Replication (replaying old patterns, can be multi-generational, fulfill

role for family parent) - Relational images both reflect the familial/historical roots of the patient’s

experiences, thoughts, feelings, styles; and, are the sources of disconnection.

Psychological Health and Pathology – con’d.

2. Malan (2001): Depression (Ch.13) – most common of neurotic symptoms

- Avoids issue of ‘neurotic’ vs. ‘endogenous’ (chemical)

- Root of Depression: feelings of loss, esp., miscarried grief that was never worked through

- trauma can be worked through unless complicated by prior experience - Grieving process can go wrong by having too

much (overwhelming)/too little (denial)

Psychological Health and Pathology – con’d.

3. C&H (2003):

- Psychological problems do not reflect illness;

- Symptoms are problematic, but adaptive. They are an attempt to forestall facing worse things and evidence patient is not optimally engaged in their life;

The Process of Clinical Assessment

• Informal assessments at all phases of therapy (see Sullivan on the therapeutic impact of history taking) and are ongoing throughout the process of treatment;

2. M&S – At all times, as it reflects the therapeutic monitoring of the connection/disconnection

• At all levels (individual, dyadic, systemic);• Looking at interactional, defensive, and coping styles;• Views of Self and Others; 1. M&S – Relational Images (sources of disconnection at times)• Diagnostic categories are known, but limit patient understanding

(and understanding of the patient);• Circumstances surrounding the patient’s problems are elicited

The Process of Clinical Assessment – con’d.

3. C&H (2003):

- No need for formal diagnosis.

- Formulation grows out of relational perspective, e.g., description of internal/external life and core conflicts;

The Practice of Therapy• Basic Structure of Therapy

1. M&S: - Provide a new relational experience - Therapist must attend to how connected/disconnected they and the patient are at all times. - Symptoms and styles are ways of staying out of relationships and guarding against yearnings for it.

- Moving in Relationship reflects that the therapist takes the patient seriously, is opened up, allows the therapist to share the patient’s experience and the patient to see that the patient is authentically heard, and as both become more empathic the therapeutic space and patient’s ability to expand her relational images in a more positive direction, as well as contemplate her own feelings and thoughts more deeply. - Therapist’s work is to always strive to make it possible for the patient to bring more of their experience into the relationship and to engage with the patient about that experience and only that experience. P.135.

• Goal Setting 1. M&S: Focus on understanding the sources of disconnection and moving from disconnection

toward connection; - Greater capacity for engaging in mutually empathic and empowering relationships, e.g., “five good things”.

– Proceeds in stages of disconnection to connection at ever increasing levels of complexity and capacity for connection.

The Practice of Therapy - con’d.• Process Aspects of Treatment

– History Taking and Inquiry

– Silence and Free Association

– Analysis of Defense and Resistance 1. M&S – What has kept the patient out of connection in relationship. Non-judgemental conceptualization which makes it easier to maintain

empathic stance.- Respect disconnection and the needs for maintaining one’s mind and containing associated pain and rage and fear of need for connection.

– Analysis of Transference 1. M&S – The transference is a real phenomenon. - Therapist need not be a blank screen and transference will emerge in the context of the relationship - Interpreting the transference is not the major work of therapy.

- Being a blank screen may impede the emergence of the transference- Therapist needs to be aware of feelings projected onto her by patient, that are dissonant with her sense of herself.

– Mutual Enactment

– Interpretation

– Analysis of Dreams: – 1. M&S – Makes use of dreams to help empathize with and through connection understand the patient’s experience.

– Encouraging Experiences in the Moment M&S – Stay in connection– Technique with Children and Families

– Technical Errors

– Termination

The Practice of Therapy – con’d.

2. Malan (2001): Regression and Long-term Therapy (gen’ly – the longer the concentrated therapeutic experience, the more completely developed the following phenomena (regression is not decompensation usually)

- Regression and Dependence:

- ‘Needs’ and ‘Demands’

- The ‘Corrective Emotional Experience’

- Transference and Transference Neurosis

The Practice of Therapy – con’d3. C&H (2003): - Basic Structure of Therapy:

- Goal Setting:

- Process Aspects of Treatment:

a. History Taking and Inquiry

b. Silence and Free-Association

c. Analysis of Defense and Resistance

d. Analysis of Transference

e. Mutual Enactment

f. Interpretation

g. Analysis of Dreams

h. Encouraging Experiences in the Moment i. Technical Errors: All choices have +-, but adhere to basic boundaries, avoid imposing own theory on patient’s verbalizations,; integrate emotion

with insight, avoid extremes j. Termination: Mutually agreed on

The Therapeutic Relationship and the Stance of the Therapist

• Countertransference 1. M&S – All the therapist’s feelings that facilitate or impede the process of staying in connection.

Derived from 1950’s revision when countertransference was conceptualized as including not only the therapist’s reactions to the transference, but also clues to how the patient was being experienced by others in relationship (character clues);- Central to the process of therapy and disentangling what is the basis for the therapist’s experience of feeling disconnected from the patient.

- Reflects the impact of the therapist’s own relational images in the therapeutic process. - Focal point for returning to connection in therapy. - The process of disclosing/not disclosing these feeling is complex and involves placing the needs

of the patient at the forefront so as to facilitate connection, not relieve the therapist.

• Self-Disclosure 1. M&S - Part of the armamentarium for maintaining connection and may reflect the empathic-

feeling use of the therapist’s personal experience to facilitate reconnection through feedback. – “…therapist must be authentically present and participating in the therapy relationship.”(p.22)

2. Malan (2001) – The therapist can be reasonably disclosing of self – see p.156 and active in the case of emergent clinical crises like suicide – see p. 152.

- Stay with them, share their experience, assist them, don’t interpret too early.

The Therapeutic Relationship and the Stance of the Therapist – con’d.• C&H (2003): Central to the Relational therapist identified

with the Interpersonal School - “concurrent transference” – therapist’s current feelings

about the patient assumed to be a facsimile of what others feel when with patient (basis for how therapist helps patient to understand what it is like for others to be with the patient);

- “Projective identifications” (Bion, 1967) or Racker’s “concordant countertransference” (1968) is Kleinian (1957/1975) and refers to those projected into the patient because they are too frightening to tolerate;

- These feelings are held or contained by the therapist ntil patient ready for them to be dealt with in therapy

- Sullivan’s concept of ‘participant observation’

Curative Factors or Mechanisms of Change

1. M&S - Sharing both thoughts and feelings which adds to expression of the person receiving them, thus “enlarging the relationship”.- sense of connection leads to increased energy and vitality that is “…most basic feature of growth-fostering interactions – and leads directly to …” – Action which results in increased Knowledge.

- the interaction endows the subject with an increased sense of Self-Worth as the author of these thoughts-feelings-actions confirmed in connection, which in turn leads to increased desire for more such experiences of connection.

- Action comes out of the interplay between actors; development is mutual rather than individual.- People create in their minds relational images of their experiences of themselves in relations with correlated explanations of these interactions (+/-) with implications for feelings/thoughts/actions regarding self-other. - Quality of relationship is important and the vessel for change - New relational images for the patient allow them to change outside of therapy and/or move on to other relationships.

Curative Factors or Mechanisms of Change – con’d.

2. C&H (2003): - New Experiences and the development of new meanings of

experiences; - Differ as to whether analysis is extra-transferential (Sullivan felt it

was too anxiety provoking for Schizophrenic patients) to transference-countertransference matrix being at the center of the therapy per Harold Searles who also works with schizophrenic and primative character-disordered patients;

- Insight that is cognitive-emotional in nature; - Balance gratification vs. deprivation so that allow the patient

expression of the feelings in the here-and-now for support and analysis by the empathic therapist.

- Mourning loss; - New self-organization;

Treatment Applicability and Ethical Considerations

C&H (2003) Patients need to be assessed so that what is provided is met with appropriate treatment techniques.

- Approach is used with a wide variety of patients; - Parameters of technique are used depending on the

nature of the psychopathology, e.g., externalizers and narcissistic patients may receive emphasis on reflective and empathic interventions;

- Adjunctive therapies may be used prn; - Clarify relative weight of symptom reduction and length

of therapy vs. Relational approach that is less symptom focused, more open ended, and longer

Research Support

• C&H (2003): Considerable support for it.

- Luborsky and Crits-Christoph have found support for it;

- Bowlby’s attachment research has been cited by Mitchell as supportive of relational approaches (see Fonagy and Blatt’s work) which indicate both representations and attachment styles change during therapy.

Current and Future Trends