临床与咨询心理学导论 16 - Psychoanalytics

L16 Psychoanalytic & Psychodynamic Psychotherapy 

参考文献/图片来源：Pomerantz, A. (2013). Clinical psychology: science, practice, and culture (3rd ed.). Thousand Oaks, CA: SAGE Publications.

16.1 Sigmund Freud & Freudian Theories

16.1.1 Sigmund Freud

• Trained as a neurologist (M.D.)

• Examples of his work:

Studies on Hysteria (with Breuer; 1895)

The Interpretation of Dreams (1900)

The Psychopathology of Everyday Life (1901)

Three Essays on the Theory of Sexuality (1905)

Introduction to Psychoanalysis (1917)

Beyond the Pleasure Principle (1920)

The Ego and the Id (1923)

The Future of an Illusion (1927)

Freud’s Early Work

• Clinical practice specializing in the treatment of hysteria

• Published this work with Breuer (1895)

- Anna O. Case: Symptoms included paralysis, visual and auditory problems, dissociative states

- Studies on Hysteria: Ideas that come up in later theories…

• Traumatic events in the unconscious influence behavior later

• Specific symptoms linked to the traumatic events

• Symptoms alleviated with identification of traumatic events

• Importance of the relationship/interaction with the therapist

16.1.2 Freud’s Structure of Personality

• Three key elements of personality

    - Id: Unconscious, driving force of personality

• Constantly demands that needs be satisfied; immediate gratification

• Present from birth

    - Ego: Partly conscious and partly unconscious, center of personality

• Develops from the id

• Keeps drives/impulses in check

    - Superego: Internalized moral standards and ideals

• Develops around 5 years old

• Influenced by caregivers, society

• Unconscious Mind

- Processes outside of our awareness have a major impact on the individual

- Includes all of the Id

- Parts of the Ego and Superego

• The Unconscious represented a major change in the understanding of behavior

16.1.3 Defense Mechanisms

• Conflict between Id and Superego causes anxiety

• Defense mechanisms are techniques used by the ego to reduce anxiety that distort reality to make us more comfy

• Goal is repression: Keeping the “bad stuff” out of awareness

Examples of Defense Mechanisms: Denial, Rationalization, Projection, Reaction Formation, Displacement, Sublimation, etc.

Denial

• Simple and immature defense mechanism

• Refusing to recognize or acknowledge that something has occurred.

Rationalization

• Providing a plausible and socially acceptable reason for a socially unacceptable behavior

Projection

• Attributing the wishes, aims, and/or motives one cannot accept in themselves to others

• Allows some gratification of repressed impulses because it allows them into consciousness but protects the individual by ascribing them to others

Reaction Formation

• Rejecting an impulse and forming a reaction against it

• “Acting opposite”

Displacement

• Reject an impulse and displace it onto safer target

Sublimation

• Reject id’s impulse and redirect it into a more socially acceptable impulse

• Thought to be one of the healthiest defense mechanisms

16.1.4 Psychosexual Stages of Development

• Importance of early experiences in personality

- Problems in adulthood often had roots in childhood

- Stages of development associated with sources of gratification

- Connected clinical symptoms to trouble transitioning between phases

16.2 Psychoanalysis

Psychoanalysis

• Treatment focused on helping client gain insight into unconscious

• Different techniques are used to access the unconscious

- Free association

- Dream Analysis

- Identifying Parapraxes (“ Freudian Slips”)

- Confronting Resistance

• Transference

- The most powerful dynamic tool

- Client responds to therapist as if they are an important figure in the patient’s past (“transfers” feelings)

- Therapist should be a “blank screen”

• Countertransference

- Therapist transfers unconscious feelings onto the client

- Should be avoided

• Meet multiple times a week for years

- Traditionally hundreds of sessions included in treatment

- Example: 3-5X per week for 2-5 years

• Very little research support:

- For efficacy of psychoanalysis

- For Freud’s specific theories about why analysis works

16.3 Contemporary Psychodynamic Approaches

Modern Psychodynamic Psychotherapy

• Compared to psychoanalysis, newer forms of psychodynamic therapy:

- Deemphasize the importance of the id

- Focus less on sexual desires

- Focus more on social relationships

- Focus more on the present

- Are shorter and more standardized

• Examples

- Time-limited Dynamic Psychotherapy

- Interpersonal Psychotherapy

Time-Limited Dynamic Therapy

• Shares tenets with traditional psychodynamic treatments

• Key differences:

- Briefer: 20-35 sessions in total

- More effective than long-term

• Techniques:

- Transference

- Resistance

- Interpretation, Clarification, & Confrontation: Therapist comments on defense mechanisms, transference, unconscious conflicts

• Results of meta-analyses (Shedler, 2010)

• For Cohen's d: 0.2 "small" effect; 0.5 “medium" effect; ≥0.8 “large” effect

Interpersonal Psychotherapy (IPT)

• Evidence-based treatment for depression, anxiety, and bulimia

- Problems views in the context of interpersonal relationships

- 14-18 sessions

Four themes of problematic social functioning:

1. Grief: Bereavement process

2. Role Disputes: Diverging perceptions of conflict with significant others

3. Role Transitions: Difficulty adapting to change life changes

4. Interpersonal Deficits: Few high-quality relationships

Phase 1:

Examine current depressive symptoms & interpersonal relationships

Link depressive symptoms to interpersonal theme(s)

Phase 2:

Monitor depressive symptoms and link to problems in theme area

Work toward resolution by improving communication and affect recognition

Develop interpersonal network to support change in focus area(s)

Phase 3:

Discuss affect associated with termination

Review and evaluate treatment progress)

• Meta-analysis (Cuijpers et al., 2011) of RCTs comparing IPT with control, other psychological treatments, and medication

• 38 IPT studies that included 4,356 patients identified

- IPT vs Control: (Cohen’s d = .63)

- IPT vs Other Psychosocial Treatments: (Cohen’s d = .04)

- Combo Treatment (IPT + Medication) vs Medication: Combo was 2.7x more effective than medication in preventing relapse

Lasting Impact of Freud & Psychoanalysis

• Modern psychoanalysis is different than Freud’s psychoanalysis

• Lasting influence of his work:

- Popularized the unconscious and understanding of unconscious processes and their impact

- Developed and popularized a language still used

- Emphasized the importance of nonbiological variables

- Highlighted the importance of early experiences and the lasting impact of early childhood on adult life