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1. PSYCHODYNAMIC Theories References: Cole & Tufano, Chapter 20 Kaplan & Sadock, pp. 193-210

3. Basic Assumptions Id, ego, superego Libido – love, sex, life force, survival Aggressive drive – hostility, death force

4. Basic Assumptions Freud: Personality structure

5. Basic Assumptions, cont. Freud’s Psychosexual Stages Oral Stage (Birth – 2 yrs.) Theme: trust Psychosis (Id in control) dependency Anal Stage (1-3 yrs.) Theme: control Neurosis (ego emerges) OCD, anxiety Phallic (3-5 yrs.) Theme: guilt Character disorder (personality disorders) Personality determined by first 5 years of life

6. Psychosexual Stages, cont. Latency (6-12 yrs.) Theme: work Sublimation of energy Self-control, learning Genital (12-18 yrs.) Theme: sexual identity Identification with same gender parent Self-identity Rebellion, replay of phallic issues

7. Basic Assumptions, cont. Defense Mechanisms Narcissistic Defenses (Oral Stage) Denial – avoids awareness of painful aspect of reality by abolishing external reality Projection – perceiving and reacting to unacceptable inner impulses as though they were outside the self. (paranoid delusions) Distortion – grossly reshaping external reality to suit inner needs (hallucinations, grandiose delusions, wish-fulfillment)

8. Defense Mechanisms, cont. Immature Defenses (oral & anal stages) Acting out – substituting behavior for affect, giving in to impulses to avoid anxiety Blocking – similar to repression, but creates anxiety Hypochondriasis – Exaggerating or overemphasizing an illness for the purpose of evasion or regression (self-reproach, avoidance of responsibility)

9. Immature Defenses, cont. Introjection – internalizing the qualities of an object, usually to avoid painful separation or to overcome fear (identification with the aggressor) Passive aggressive behavior – expression aggressiveness indirectly through passivity, masochism, or turning against the self (depression)

10. Immature defenses, cont. Regression – returning to earlier libidinal phase to avoid the tension & conflict evoked at the present level of development (can be normal, such as when relaxing & letting out tensions through sexual or creative activity) Somatization – converting psychic derivatives into bodily symptoms to avoid facing unresolved conflicts (conversion disorders)

11. Immature defenses, cont. Controlling – Attempting to regulate events or objects in the environment to minimize anxiety & resolve inner conflicts (anal) Displacement – Shifting an emotion or drive cathexis from one idea or object to another (misplaced anger, i.e. mad at boss, yells at wife). Externalization – tending to perceive internal factors in external objects (house is gloomy, instead of “I feel depressed”), similar to projection but usually non-human objects

12. Immature defenses, cont. Inhibition – consciously limiting ego functions to avoid anxiety Intellectualization – Excessively using intellectual processes to avoid emotions Isolation – separating an idea from its affect (which is repressed) “splitting” Rationalization – offering rational explanations to justify attitudes/feelings

13. Immature defenses, cont. Dissociation – temporarily but drastically modifying one’s sense of personal identity to avoid emotional distress (multiple personality) Reaction formation – transforming unacceptable impulses into their opposite (overcompensate, obsessive traits, OCD) Repression – expelling from consciousness distressing ideas, feelings or events. Differs from suppression in that it cannot be voluntarily recalled (Central Park jogger, trauma blocked) Sexualization – endowing object/function with sexual significance it did not previously possess (moustache fetish)

14. Mature Defenses, review Altruism Anticipation Asceticism Humor Sublimation Suppression Ref. Sadock pp. 205-209

15. Defenses, summary Purpose: protect the ego, prevent personality disintegration What is common to avoid in many defense mechanisms? Answer: Anxiety (forbidden impulses) Why do we need to study defenses? Answer: Basis for understanding otherwise unexplainable client behaviors (mental illness & reaction to physical illness) Example: Reactions to chronic pain Obsessive Compulsive vs. Hysterical style (Curry)

16. Basic Assumptions, cont. Functions of the Ego Control & regulation of instinctual drives Delayed gratification Self control (mediator between ego & id) Pleasure principle Reality principle Language & logical thought Judgment – ability to anticipate consequences of actions (use logical thought to assess how contemplated behavior may affect others)

17. Functions of the Ego, cont. Relation to Reality Sense of reality – sensations, boundaries Reality testing – distinguish internal from external ( a higher level example of this function is consensual validation) Adaptation to reality – ability to develop effective responses to changing circumstances

18. Functions of the Ego, cont. Object Relations – ability to form mutually satisfying relationships & to integrate positive & negative aspects of others An object is that which gratifies a need Objects can be human or non-human Stages of separation/individuation from maternal object are: Autism, symbiosis, differentiation, practicing, rapproachment, and object constancy (Mahler) Process leads to development of sense of self

19. Explanation of Mental Illness Psychosis: schizophrenia, depression, bipolar, psychotic disorders Develop from failure to differentiate id & ego Primary process dominates (hallucinations & delusions, cannot differentiate from reality) Neurosis: anxiety disorders, OCD, PTSD, etc. failure of repression awareness causes heightened anxiety defenses exaggerated in attempt to control anxiety

20. Explanation of Mental Illness, cont. Character (personality) disorders: borderline, anti-social, schizoid, dependent, etc. Success of repression (don’t have insight) Persistent pattern of reaction formation and sublimation Character refers to a persons typical pattern of adaptation to internal & external forces Personality disorders stem from the exaggeration of certain character traits at the expense of others Persons with character disorders have a poor sense of self & tendency to blame others for problems

21. The End Next time: Ego Adaptive Theories in OT

22. Ego Adaptive Theories in OT Overview Basic Assumptions: Ego Psychology, some concepts from humanism, spirituality Function-dysfunction continuums Levels of personality organization (Freud & Erikson developmental stages) Mosey: drive-object skill development (based on object relations theory) Development of self-awareness & insight

23. Ego Adaptive Overview, cont. Postulates of change: Development of ego skills through interaction with objects (both human & non-human) Working through: Use of therapeutic relationship to resolve conflicts & develop self-awareness & insight Corrective emotional experiences with therapist and/or with group interventions Motivation: Drive reduction, anxiety reduction, pleasure principle

24. Ego Adaptive Overview, cont. Assessment: Projective assessments Emotional & spiritual dimensions Observation/report of Social interaction & Relationships Mental Status Interventions: Expressive/creative media Group interaction Therapeutic use of self: dyadic interaction Pet therapy

25. Multiple Neo-Freudian Theories Erikson, Sullivan, Lewin, Fairweather, Edelson, Morton (see Fidler article) Object Relations Ego Psychology Occupational Therapy: Ego Adaptive Lela Llorens (ego functions) Gail Fidler (task oriented groups) Anne Mosey (drive-object skills)

26. Ego Adaptive Frame of Reference First identified by Llorens (1966-67) – “developing ego functions in disturbed children” Used “milieu” as “growth facilitating environment” Looked at psychological needs as well as functional capacities Need for love and affection Feeling of belonging Expression of aggression Discipline, self-control Sense of mastery, self-worth

27. Llorens, cont. Children need ego functions to cope effectively with everyday life situations Placed children in OT groups to develop physical skills (eye-hand coordination, etc.) behavioral characteristics ability to relate to others Incorporates some aspects of behavioral theory, such as ignoring bad behavior & providing structure & routine

28. Llorens, cont. Three phases of treatment Evaluation Convalescence Treatment Phase 1: Evaluation Group meets 3 consecutive days for 1 hour Written background information sheet Orientation to occupational therapy Completion of small mosaic tile tray

29. Llorens, cont. Phase 2: Convalescence Includes those with abnormal ego functions Uses modalities: leather, woodwork, needlework, metal work, etc. 5 to 15 clients, two therapists Goals: Acceptable expression of needs, sublimation, increase attention, reality testing, orientation, verbal & nonverbal emotional expression

30. Llorens, cont. Phase 3: Rehabilitation Those with more highly developed ego skills Involves more interaction Uses a less directive leadership style Modalities: male & female interest groups, activities of daily living, discussion, graceful living, typing, & cooking. Mastery is both the motivation & the goal.

31. Gail Fidler – Task Oriented Groups Published 1969 Cites ego psychologists: Lewin, Sullivan, etc. as theorists Points to “emerging focus on ego functions and adaptive skills” Relationship between problems encountered in task groups & problems encountered in outside world (social microcosm theory) Ref. Cole, Group Dynamics, Appendix A

32. Fidler, cont. Three phases of task oriented groups: Planning, Doing, Evaluation Tasks: end product or service to those inside or outside the group Ground Rules: All members work on same task Task should be meaningful to all members All members must participate

33. Fidler, cont. Planning: Brainstorming Persuasion Decision – must be unanimous Specific planning & division of labor

34. Fidler, cont. Doing Members organize task Therapist acts as facilitator Therapist intervenes as problems emerge Members carry out task without therapist intervention whenever possible Allow group to experience the consequences of their own actions Goal is learning, not task completion

35. Fidler, cont. Evaluation Time set aside at the end of both planning & doing to evaluate session Reflection on process and problems that arose during planning/doing Discuss how group felt about task outcome Reflect on behavior and its consequences Discuss how group learning relates to world outside the group (application in life)

36. Task Group Goals Encourage development of the following ego functions: Decision making, Problem-solving, Judgment & anticipation of consequences Reality testing (consensual validation), Emotional expression (socially acceptable) Cooperating and negotiating to meet own needs & those of others.

37. Mosey: Object Relations (published 1970) Object: that which satisfies a need People as objects: Anaclytic object choice: nurturing/dependency Object constancy: sustained mental image of object Object libido: love of others Ego libido: self-love Mourning: results from object loss Object choice in later life: guided by culture & social norms Nonhuman objects: Transitional objects: develop independence Activities as objects: satisfy needs, sublimation

38. Result of Disturbances in Object Relations (Bellak) Emotional coldness Detachment Inability to fall in love or sustain love Helpless dependency on others Need to dominate others Perversions

39. The End Let’s Practice: Class Exercises: Draw a person doing something. Groups do Magazine Picture Collage (Lerner, in Hemphill) Psychodynamic Toolbox (Chapter 20)

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