PSYCHODYNAMICPSYCHODYNAMIC(PSYCHOANALYTICAL)

• Theoretical base: Psychiatry, psychology: striving for need fulfillment.

• Theorist: Freud, Jung, Sullivan, Fiddler.

• Based on premises that when a person is not capable of rational choices, his/her behavior - determined by unconscious drives & past experiences & feelings which may be analyzed to provide explanations of current behavior & emotions.

• Origin of problem:– Deficit or lack of integration of

personality stemming from unconscious causes.

– The problem described within language of particular theory- Unresolved conflict, fixation in regression to an early development stage, lack of insight, failure to acknowledge sexuality, faulty early relationships with a parent.

Sigmund Freud

• Born 1856, died 1939• Single most influential theorist • Attempted to explain previously

unexplainable phenomenon regarding mental disorders:– Psychosis– Neurosis– Character disorder

The Psychodynamic Model

• Main assumptions:– Psychological disorders are caused by

emotional problems in the unconscious mind

– The causes of these emotional problems can usually be traced back to early childhood

– The relationship between child and parents is a crucial determinant of mental health

Primary Assumptions– Behavior is governed by unconscious

processes, linked to gratification of basic drives.

– Subconscious material may surface in form of dreams & symbols which may affect perceptions of reality.

– It is possible through lengthy process of analysis to recover origin of symptoms, to bring material out of unconscious, to gain insight, & thereby to resolve conflicts, anxieties, & unsatisfactory relationships.

The Unconscious Mind

The preconscious. Things we could be aware of if we wanted or tried.

The unconscious. Things we are unaware of and can not become aware of.

ThoughtsPerceptions

MemoriesStored knowledge

FearsUnacceptable desiresViolent motivesIrrational wishesImmoral urgesSelfish needsShameful experiencesTraumatic experiences

Bad

Worse

Really Bad

The conscious. The small amount of mental activity we know about.

From Cole, M. From Cole, M. Applied theories in occupational therapy: a practical approach instructor's manualApplied theories in occupational therapy: a practical approach instructor's manual. Online document, http://www.efacultylounge.com, . Online document, http://www.efacultylounge.com, based on Cole, M. (2008). based on Cole, M. (2008). Applied theories in occupational therapy: a practical approachApplied theories in occupational therapy: a practical approach. Thorofare, NJ: SLACK Incorporated.. Thorofare, NJ: SLACK Incorporated.

Freud: Personality structure

Defense MechanismsID: Unconscious needs Dreams, free Association

Pleasure seeking Projective testsLibidinal & Aggressive DrivesPrimary ProcessSymbolsConflicts & Fixations

EGO: ConsciousSecondary ProcessMemory & IntellectRational Thought SuppressionLanguageEgo functions (Bellak) Repression

PRE-CONSCIOUS: (Superego, morality, shame, guilt, remorse)

The Psyche

Id:

Instincts

Superego:

Morality

Ego:

Reality

Healthy Psyche

Id Superego

Ego

OK Guys – I’m in charge. Anything you want has to go

through me.

OK.OK.

Neurotic Psyche

Id

Superego

Ego

Listen up! I’m in charge, and you are not here to enjoy yourselves. Get ready for a double-

size portion of anxiety with a side order of guilt!

No fun.

>whimper<

Psychotic Psyche

Id

SuperegoEgo

Food! Drink!.......... NOW!

Who turned out the lights?

Psychopathic Psyche

OK. First, give me food. Then I want ………………………………, ………… Then I

want to hurt people. Badly. Probably be hungry again after that so……….

OK then. Let’s go.

Freud’s Psychosexual Stages

• Oral Stage (Birth – 2 yrs.) Theme: trustPsychosis (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

Defence Mechanisms

• Unacceptable (latent) motives are channeled into more acceptable (manifest) thoughts and actions

Defense Mechanisms

• Narcissistic Defenses – 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)

Defense Mechanisms, cont.

• Immature Defenses– 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)

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)

Immature defenses, cont.

• Somatization – converting psychic derivatives into bodily symptoms to avoid facing unresolved conflicts (conversion disorders)

• 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)

Immature defenses, cont.

• Controlling – Attempting to regulate events or objects in the environment to minimize anxiety & resolve inner conflicts (anal)

• Displacement – Shifting an emotion 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

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

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. (trauma blocked)

• Sexualization – endowing object/function with sexual significance it did not previously possess (moustache fetish)

Mature Defenses, review

• Altruism• Anticipation• Asceticism • Humor• Sublimation• Suppression

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

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)

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

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

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

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

OT ASSESSMENT• There may be no clear distinction between

assessment and treatment.• Open ended interviews, projective tasks,

focus on inference.

Treatment modalities: Creative and unstructured activities like drawing, painting, writing, clay modeling, finger painting, psychodrama, music therapy.

INTERVENTION APPROACHES• Two main approaches: Explorative & supportive• Explorative approach:

– Assumption -Content of unconscious mind can best be dealt with by bringing it into conscious so that it can be shared and examined, as in projective activities.

– Then the individual can find ways of resolving conflict and accepting difficult or painful feelings so that more adaptive ways of meeting needs can be achieved.

– Projective activities:• Used for assessment and treatment.• Projection as a defense mechanism allows

unacceptable feelings to be put outside the individual, onto another person or object.

• Have potential as diagnostic and prognostic tool.

• Supportive approach:

– Aims to keep unresolved conflicts and painful feelings hidden in the unconscious mind and to strengthen the patient’s ego defense mechanisms so that material may not ‘leak’ into the conscious mind and cause problems. E.g. supportive group therapy.

• Important, factors to be considered

– Psychodynamics of activity– Symbolic potential of materials– Interpersonal aspects– Sociocultural significance

• Whichever approach is used, the goal of intervention may be to:– Assist in finding ways to gratify frustrated basic

needs.– Reverse psychopathology.– Provide conditions for normal psychosexual and

psychosocial development.– Facilitate the development of a more realistic

view of self in relation to action & to others.– Help to build a more healthy & integrated ego.

• Therapeutic elements of O.T. in both approach are:– Action of client.– Objects used in, or resulting from, the action.– Human & non-human objects in the environment.– Interpersonal relationships.

– Satisfaction of needs.

Contd……• Process of intervention:

– Choice of activities• may be either by client or therapist• depending upon needs of client• client must be active participant in

therapeutic process

– Treatment may be • Individual • Groups

– group should always be small enough to allow individuals to relate closely to everyone in it

– maximum 8 to 10.

INTERVENTION

– Begin with collection of relevant data of client

– General goals of multidisciplinary team– Data analysis allows

• Tentative treatment plan to be drawn up • Or preliminary program devised for further

collection of data.

– Close liaison with other team members essential

– Treatment planning takes into account • Amount of support • Structure available to client outside of

treatment sessions.

• Patient/ therapist relationship:– Complex relationship occurs during

extended process of analysis – Involves mechanisms such as

projection, transference& counter transference

– Although OT is not functioning as analyst such relationship may develop, & therapist may be aware of his/her own mechanism of defense or transference

– Patient may develop dependence on therapist.

• PATIENT POPULATION:– Anxiety states, affective disorders,

failure to develop positive self image, feeling of guilt & unworthiness, failure to develop satisfactory relationships, phobias.

• Advantages: – Focuses on emotions & relationships, releases unconscious

material & makes it accessible. Recognizes an irrational basis for behaviour.

• Disadvantages:– Highly subjective process– Slow, results may not be apparent until months or even years

after therapeutic interventions or experiences.– Patient may become dependent on therapist.– For OTs it requires expertise, misinterpretation could be

misleading or damaging.

– Releasing unconscious material without dealing with it appropriately may produce violent emotional reactions & behaviors.

– Techniques may be stressful for therapist if she uncovers personal material or emotions

• Note: Therapist needs to work under supervision of trained psychotherapist.