1. Psychoanalytic Psychotherapy:Self/DevelopmentalM.F. Basch PSYC E-2488 – Lecture #3 10/15/07

2. Historical Background • Freud and Psychoanalysis • Freud’s Followers and Rebellious Students • Norbert Wiener (1948) Cybernetics • Sylvan Tomkins (1962-70) Affects, Imagery, Consciousness and Motivation • Ludwig von Bertalanffy (1968) General System Theory • Hans Kohut (1959-1987) Empathy and Self Psychology • 1960-1980 Proliferation of Therapeutic Theories and Forms (see JT Carpenter, 2004) • Self/Character Pathology – Psychoneurosis • Early Theoretical Speculations and/or Therapy Techniques (likely limited by Basch’s medical school and institute milieu)

3. The Concept of Personality • A Core Organizing Concept that is the Integrative Framework for Freudian and Subsequent Psychoanalytic Concepts, as Well as More General 20th Century Scientific Theories. • The Basic Concepts Used to Understand Patients Include: Self-Image, striving for competence/mastery, developmental spiral (self-esteem, decisions, behavior, competence) in the context of current circumstances and history, pattern matching (how brain orders things – bringing meaning to chaos and a reduction in perturbation), feedback cycle, affect as motivator, self-system, affective layering of character • The Theory of Personality Development is a Combination of Developmental Psychopathology and Stage Theory (including classical Freudian psychosexual development)

4. Psychological Health and Pathology • The Diagnostic Framework is Psychodynamic and Similar to the Earlier Forms of the DSM in Terminology. • Symptoms and Problems Develop when life events lead to conflict, loss of adaptive capacity, and closing of the self-system. • Type of Symptoms and Problems is Determined by genetics/temperament, personality, history (both particulars and h/o stage resolution), resources, stressors • Dimensions Relevant to Psychological Dysfunction Include nature of traits (idea of continuum of function with dysfunction at the extremes), levels of personality organization (neurotic, borderline, psychotic) • Using Cybernetic Concepts, an Open System (adaptable) is a Healthy Self System and a Closed Self System is a Pathological One

5. The Process of Clinical Assessment • Assessment is Made at the Individual Level, but May Be Informed By the Dyadic and Systemic Contexts. • The Health of the Self System is Determined by the Patient’s Intra-psychic Functioning, as Well as By the Patient’s Behavior and Systemic Functioning. • Cultural Factors Serve to Contextualize and Determine What is Problematic vs. What is Normative. • Tests Not Typically Used – Assessment is Ongoing. • Assessment is Integrated Into Treatment. • A Patient’s Strengths and Weaknesses are Integral to Determining Psychic Structure, and the Appropriateness of Treatment Forms and Techniques. • Factors and Dimensions Indicative of Dysfunction Include • Standard Diagnosis is Correlated with Diagnostic Formulation and Assessment.

6. The Practice of Therapy • Basic Structure of Therapy - Monthly to 5X/Week Depending on Form, Phase, and Needs of Patient. - Psychoanalysis is not Time-Limited, but Psychotherapy is More Variable. - Multiple factors such as nature of problem, patient’s motivation, life events, etc. Months – years. 45 minutes. • Goal Setting - Depends on patient/therapist contract (varies from evaluation, to short term symptom relief, restoration of self-system and adaptive functioning, to resolution of the Oedipus • Process Aspects of Treatment - Strategies reflect therapist’s assessment of fit, psychodynamic assessment of problem, and motivation. Less structure at higher levels of function and later phases of treatment. Nature and level of intervention determined by formulation (e.g., symptom, context, character, resources) - Not homework in the usual sense, but more structure and direction (parental model) in acute and critical stages (usually at outset) with monitoring of progress as part of therapy cybernetic process.

7. The Practice of Therapy con’d. • Resistance to therapy may be a function of severity of symptoms and closure of system. Dealt with by becoming an understanding and empathic part of the patient’s self system (with adjunctive supportive structure and psycho-pharmacotherapy as needed). - Vicious circle of anxiety and depressive symptoms - Concept of defensive functioning utilized (Freudian rather than revisionist ego psychological terminology of A. Freud): Withdrawal (to control over-stimulation), primal repression (arrested development in which sensorimotor patterns for coping not transformed into ideas), secondary repression (repression proper-disrupts connection between affective memory and words), disavowal (blocks formation of bond between perception and affect), and the corollary failure of defense - 6 Phases of Therapy: Orientation, consternation, reorientation, collaboration, integration, and transformation. - Termination is a collaborative decision based on evaluation of mutual expectations and resolution of presenting issues as defined by the therapist and the patient.

8. The Therapeutic Relationship and the Stance of the Therapist • The Affective Bond (both in the relationship with the therapist and in the manner in which the affective layering of character is managed) • The Development of the Transference (3 types- idealizing, mirroring, alter ego) • The Form of the Transference • The Role of Empathic Understanding • Therapeutic relationship affects outcome to the extent that it forms the basis for a therapeutic alliance, provides experiences which both resolve internal trauma/defects in self system as well as leading to improved mastery and adaptation at a higher level of functioning. • Therapeutic relationship both fosters the development of transference (neurosis in psychoanalysis) and constitutes the container within which the problematic aspects of self are transformed positively leaving the patient free to more spontaneously cope and adapt with full access to his/her experience. • Therapist is only as active as the patient’s condition and therapeutic trajectory require: More structure earlier and for more supportive psychotherapy and less for less severe conditions and more psychoanalytic stance to resolve the Oedipus.

9. The Therapeutic Relationship and the Stance of the Therapist con’d. • Therapist is a partner in the change process – responsibility for change is shared. • Therapist self-disclosure is governed by patient’s therapeutic need and the therapist’s insight and inclination. The therapist is a person, but not a peer. • Therapist’s role changes over the course of therapy. Termination both requires a tolerance and need to support and evaluate the expected regression and resurfacing of symptoms, but also to gradually step away from an active role appropriate to the initial stage of therapy. • Counter-transference is that which the therapist experiences in relationship to the patient and which may negatively impact the management of the treatment relationship. Counter-transference may also inform the treatment and choice/form of techniques. • Valuable clinical attributes that are essential to successful treatment include empathy, the capacity to be both neutral and containing in the context of transference, self-knowledge, a relatively secure self-system

10. Curative Factors or Mechanisms of Change • Therapeutic relationship, transmutation of pathological internalizations, empathic responding, capacity to provide appropriate transference objects (based on patient’s developmental needs), neutrality and appropriate interpretations, contain/utilize counter-transference • Patient’s capacity for insight is disorder/phase specific, an indicator of level of functioning/response to treatment, and an ultimate goal of treatment (e.g., different levels and types) • Interpretations take genetic history into account. The nature of the interpretation reflects level of function/psychodynamics, phase of treatment, and goals of treatment. The interpretation reflects both an independent and a personal reality; and, a mechanism by which the blockages to higher adaptive functioning are removed. • Learning of new interpersonal skills seems to be a result of the experience of the here-and-now with the therapist and a relatively spontaneous by-product of the impact of the therapy on the self-system and transference. • The therapist’s knowledgeable and relatively healthy personality is necessary for the formation of the relationship and the provision of therapeutic interventions.

11. Curative Factors or Mechanisms of Change con’d. • Techniques are important for how they both reflect important therapeutic qualities in the therapist; and, for how they accomplish some of the work of therapy. It is a recursive feedback loop or developmental spiral re-created by the therapist at the point in the developmental spiral which reflects the point of the closure of the system; and, is the point where the therapist can enter the self-system and make it a bi-personal exchange with the patient, transforming a closed system into an open one again. • Motivation, resources, skill, supports, severity of illness, therapeutic match between therapist, all influence outcome. • Understanding and management of termination dynamics determines level of resolution of presenting problems. • The Self/Developmental model of therapy shares many common factors, e.g., client factors (motivation and expectation of change) , therapist factors (warmth, ability to form a therapeutic relationship, empathic attunement), structures for treatment, strategies for change, helping relationship, restoration of morale, mutual problem solving, formation of meaning, but differs (in various way) in terms of terminology and explanatory constructs, theory, and causal relationship between components, process, and outcome.

12. Treatment Applicability and Ethical Considerations • Developed on and used for character pathology (borderline – split/precarious self; and, narcissistic – excessive self-absorption and grandiosity, conditions), character neurosis, and psychoneurosis. • Requires considerable modification of parameters of technique for use with psychotics and then likely only partially applicable.

13. Research Support • Limited to clinical observation and may be reflected in Menninger Study of Long-term Psychotherapy (supportive and expressive), John Clarkin et al.’s work at NY Hospital –Cornell/Weill Medical School. Will be covered in outcome research reviewed and integrated by London psychoanalyst Peter Fonagy

14. Case Illustration

15. Current and Future Trends