“Where id is, there ego shall be.”: Freud and Psychoanalysis.

Lecture #2 – 10/1/07

Class Exercise

• Take out a clean sheet of paper and for the next 5 minutes write down whatever comes to mind.

• Don’t censor or share the material with others.

• If you find yourself uncomfortable with the exercise you can stop. It is not necessary to complete it.

Exercise con’d.

• What did you find ?

• What did/do you think ?

• What did/do you feel ?

• What behavior do you associate with what you wrote ?

Exercise con’d.

• Does the process tell you anything about yourself ?

• What might you do with that information ?

• What would a therapist do with that information ?

Exercise con’d.

• Share what you feel comfortable sharing with the class.

Exercise con’d.• Purpose of exercise:

• Introduce you generally to the following psychoanalytic concepts: - technique (free association) - conscious, preconscious, unconscious content - unacceptable impulses - relationship of content and impulses to personality - levels of personality functioning - defensive functioning - relationship of task and content to circumstances - idiographic and nomo-thetic nature of psychoanalytic understanding

Who Was Freud and Why Should We Care?

• Historical Background:• Childhood - Victorian Vienna (organized by class/royalty, sexually restricted, authoritarian, Christian) - Child of father’s 2nd, younger wife - Jewish/agnostic (discriminated against minority) - Medical doctor/researcher, excellent mentors who were authors of some of the dominant scientific concepts in their

times. - Unable to secure research/academic position (prior to which he did research monographs of animal nervous systems, translated French work on hypnosis, and

later wrote monographs on aphasia and cocaine). - Went into private practice and in case of conjoint treatment of Anna O. with senior colleague Breuer, became

interested in treatment of hysteria using hypnotic and cathartic techniques. Theory and techniques presented in professional meetings to some controversy. Breuer and Freud (1895) “Studies in Hysteria”. Initially said women were sexually molested by men in or close to family. Later modified to suggest that symptoms were based on developmental fantasy.

- Initially thought that women were afflicted by memories of their trauma which was reflected in split off consciousness with associated affects and disruption of normal sensation and discharge when stimulated. Clinical techniques were thought lead to a reintegration of affect and conscious awareness as the unwanted ideas were reintroduced into awareness and the split-off affects discharged, leaving a normally integrated and functioning nervous system.

- Case Data: Patients typically young women with hysterical symptoms, e.g., functional blindness, paralysis, convulsive-like motor actions (e.g. trembling) and anesthesia (i.e., diminished sensation)

- Cases discussed over subsequent years with Wilhelm Fliess, while in isolation, with periodic annual “congresses”. - The science was more formally introduced to the world with the publication of his (1900) “The Interpretation of

Dreams.”

The Concept of Personality• Personality is a meaningful concept, but is reflected by a variety of evolving and inter-related concepts from the inception of psychoanalysis and over

time into variant forms. Initially, the personality was viewed as a relatively unarticulated context for the symptom which was to be treated and removed. This unarticulated context took shape progressively as Freud refined and developed his theories.

• Basic Psychological Concepts Used to Understand Patients: - Initially patient seen as deceiving self by keeping the idea repressed and out of awareness due to its socially unacceptable nature and attendant negative

affectivity. The dynamic conflict interfered with homeostatic functioning. • What is the Theory of Personality Development Used in this Approach:

- Child is born in state of “primary narcissism” and in this prolonged state of helplessness relies on the mother to regulate homeostasis and mediate development (self-other differentiation and growth)

- 2 basic principles governing mental life: Reality and Pleasure

- Psychic structure: * Primary and Secondary Process Thinking * Wishes (memories of satisfaction create the desire to reinstate that condition through “perceptual identity”) * 2 major drives (characterized by a source, intensity, aim, and object) libidinal (sexual in a general sense) and aggressive which produce excitation that

motivates the organism to discharge * Freud initially believed excitation not discharged created anxiety * Intra-psychic conflict: anticipation that satisfaction of a wish is dangerous leads to signal anxiety (approach-avoidance conflict). * Developmental hierarchy of typical childhood danger situations is: loss of object, loss of object’s love, castration anxiety, and guilt (last 2 based on

threat of loss of object’s love) * Anticipation of danger gives rise to defenses - Stage Theory: oral, anal, phallic, ,latency, and genital (focus is on developmentally emergent sources of pleasure the satisfaction of which is mediated by

the environment) - Fixation and Regression (symptoms are symbolic of psychodynamic basis of conflict)

- Mind in state of dynamic equilibrium as it tries to balance demands to maximize pleasure and minimize pain.

Personality con’d.

• Core inter-related propositions: * Principle of psychic determinism: All mental life is lawful and has causes * Much of mental life occurs outside of conscious awareness and motivates

behavior. It is known primarily indirectly through “accidents” and “slips” (e.g., parapraxis – slip of the tongue)

* All behavior is motivated to balance being over-whelmed by excitation and maximizing pleasure and minimizing pain

* Conflict is a given. Behavior reflects compromises in attempts to gratify drives and the constraints against that gratification.

* Signal anxiety (small am’ts) is an alert to mobilize defensive functioning to avoid awareness and/or mobilize behavior to gratify UCS wishes. If these actions aren’t taken, organism is overwhelmed.

* A complete explanation of behavioral phenomena should include multiple levels of explanation (e.g., genetic-developmental, adaptive-defenses mediating ego/id/superego, dynamic-nature of conflicts, topographic-, economic, and structural-id/ego/superego)

* Principal of multiple determination (facts of divergent and convergent causality)

Personality con’d.

- “complementary series”: the interaction of genetic/constitutional and environmental factors in producing behavior.

- Anna Freud and the contributions of “ego psychology”

- Mahler’s studies of separation-individuation

- Jacobson et al. and the contributions of self-psychology

The Principal Rule

• Say whatever comes to mind.

Psychological Health and Psychopathology

• Can the person work and love ?• How well do they adapt to the “average expectable environment” ?• Are the “compromise formations” between the constituent elements of the personality

“maladaptive”?• Is the person able to arrive at reasonably satisfying solutions to the problems of

integrating drive pressures, superego demands, and external reality ?• Is the wish too strong and the defense too weak so that the symptom shows too

much defensiveness and not enough acceptance of the wish and its underlying gratification ?

• To what extent does the symptom maintain its existence through primary gain (gains freedom from dysphoria by a partial satisfaction of a wish) and secondary gain (through escape from normal responsibilities).

• Character ( unique constellation of traits, conflicts, coping styles, attitudes, values) problems reflect an egosyntonic personality pattern that is dysfunctional with respect to identity, interpersonal, and affective functioning. This is a result of the interaction of biopsychosocial environmental factors and is stable across multiple contexts. It is a result of identifications with significant others and defensive coping styles for dealing with conflict.

The Process of Clinical Assessment

• Clinical interview that focuses on the intra-psychic world of the patient - other data is useful to the degree it illuminates the functioning of the patient’s inner world.* Testing is rare, except for dealing with blockages in treatment• Interviewer focuses on current and past functioning, including the nature, onset, duration,

intensity, and fluctuation of symptoms.• What are the defenses and core conflicts• Capacity for psychoanalytic treatment (psychological mindedness, regression in service of the

ego, motivation for change, frustration tolerance, control of impulsivity)• History of satisfying relationships• Is there a good match between the analyst and patient?• Does the patient have the resources, time, and environment to undergo this lengthy and

expensive process ?• Not much emphasis on formal DSM diagnosis, but there is a recently published Psychodynamic

Diagnostic Manual (PDM)(2006) published by the Alliance of Psychoanalytic Organizations.• Kernberg has a system based on his work with BPO which focuses on diagnosing different levels

of personality structure (based on British object-relations, ego psychology, Mahler and Jacobson on self-object differentiation)

- 3 levels: neurotic, borderline, psychotic, assessed by examining 4 psychological domains (superego development, object relations, instinctual strivings, and defensive ego operations)

The Practice of Therapy• The Structure of Therapy - Quite variable in duration and form (evolved from a few months to years

and then back again); form has always been a source of debate and disputation.

• The Conduct of the Sessions: Depends on whether it is psychotherapy or psychoanalysis

• Goal Setting: Depends on many factors. Considered a motivating factor in brief work

• Process Aspects of Treatment: - Transference (analysis of,+/-, regressive, transference neurosis, “here-and-

now”) - Resistance - Interpretation

Process of Therapy

• Working Alliance

• Working Through

• Termination

The Therapeutic Relationship and the Stance of the Therapist

• Analytic Neutrality

• Empathy

• Countertransference

Curative factors or Mechanisms of Change

• No single factor• General consensus on conditions predisposing to change: (1) - emotional suffering - motivation to change - some psychological-mindedness - adequate ego strength - h/o interpersonal relations sufficient to form and sustain a working

alliance (2) - a therapist who can provide safety and be catalytic for change - can facilitate a working alliance in spite of inevitable ruptures - is relatively free of unmanageable countertransference - provides accurate and empathic interpretations

Factors and Change con’d.

• Foregoing factors can be broadly classified into two main categories (not mutually orthogonal, but interactive in a context)

1. Insight

2. Relationship

* Relative power of factors may shift according to the diagnostic formulation and the needs of the patient. More primitive patients benefiting more from relationship than insight

Treatment Applicability• Social Class: Tend to be most useful with educated and verbal

• Types of Patients and Patient Pathology - Patient Populations: Some types of patients are better treated with more targeted

treatments. Character issues remain the treatment focus of choice for psychoanalysis, but Malan and colleagues have demonstrated that they can do effective focused work on anxiety, relationship, and depressive issues as well.

- Range of Pathology: Schizophrenia to anxiety, but must consider parameters of technique

Cultural Factors

Ethical Considerations: See Klerman and Chestnut Lodge case in which anti-depressants weren’t used resulting in needless suffering and lost time.

Matching Patients with Therapeutic Modalities and with Therapists

Research Support

• Mixed: • “ Dodo Verdict” – “All have won and must have

prizes.”

• Need to control variance and stick close to surface to insure construct validity

• Clarkin et al at Weill-Cornell in NYC and Peter Fonagy have done recent work showing support for psycho-dynamically informed treatment which we will cover in lecture on outcome

Case Illustration

• See Malan and his gradual enlargement and integration/interweaving of the scope of psychoanalytic theory and technique with psychopathology from common place/common sense observations to the more complex analysis of multipli-determined symptoms/behaviors within a complex personality and average expectable environment in which the precipitating stimuli are gradually isolated and their dynamic interplay with the contextualized individual is articulated according to traditional Freudian concepts.

Intrapsychic

• Definition: “Being or occurring within the psyche, the mind, or personality.”

- Merriam-WebsterFreud saw the contents of the psyche as those

memories, motives, wishes, anxieties, and regulatory capacities that developed in the organism over time as reflecting both a developmental interaction between endowment and environment; and, as being in an ongoing dynamic conflict with the environment and each other.

David Malan: From Common Sense Through Complexity, with

Scientific Observation.

David Wolitzky: Traditional Psychoanalytic Theory and

Practice.