Psychodynamic Interpersonal Therapies Melissa Stern PSY 4930 October

Psychodynamic & Interpersonal Therapies Melissa Stern PSY 4930 October 24, 2006

History n Developed from adult techniques-psychoanalytic theory of Sigmund Freud Late 1800 s-early 1900 s in Austria n Theory of development, personality, and psychopathology n This theory influences almost all psychological theories today! n

Freud’s Psychoanalytic Theory n Id: predetermined set of psychological needs, drives, instincts n n Superego: internalization of the moral principles/rules of society n n Seek pleasure, avoid pain “conscience” Ego: awareness of one’s self and ability to interact with the world n Balances id and superego

Psychoanalytic Theory The three aspects of personality inevitably come into conflict with each other n Conflict = anxiety n However, much of this conflict is unconscious due to defense mechanisms n

Defense Mechanisms Denial n Repression n Intellectualization n Rationalization n Displacement n Sublimation n And many others… n

Psychoanalytic Theory n Stage Theory of Development n n n Oral stage—sucking and feeding Anal stage—control bodily functions Phallic stage—Oedipus Complex Latency phase Genital phase Individuals can become “fixated” at various stages if the issues at each stage are not mastered

Psychoanalytic Theory n Freud worked with only a few type of psychological conditions: n n n Conversion disorders Hysterias Most psychopathology involved underlying sexual or aggressive instincts Rely on single case studies Psychological or physical symptoms = internal conflicts

Psychoanalytic Theories n A variety of more recent theories were developed from Freud’s original ideas: Erickson’s stage theory of psychological development n Object relations theory n Attachment theory n Interpersonal approaches n

Psychoanalysis n n n Primary goal = help individuals achieve insight into the origins of their distress Seeks to bring about more global personality changes Methods used: n n n Hypnosis Free association—to eliminate conscious control over thoughts Dream analysis—ego controls are relaxed during sleep

Psychoanalysis n n n Resistance—patient is motivated to continue using defense mechanisms Transference—patient “projects” their unconscious thoughts/feelings onto therapist Catharsis—experiencing of emotions previously repressed Interpretations Working through—repeated interpretations of patients behavior and feelings

Psychodynamic • • Not so ambitious goals Focused Not so intensive Less intensive therapist training • Flexible Psychoanalytic • • Ambitious Global Intensive therapist training • Focus on understanding origins • More rigid

Psychodynamic Approaches with Children Assume that the child has deviated from normal development n Play is used as the child’s way of communicating n More focused on the development of a relationship with the child n Anna Freud, Melanie Klein n

Change in Psychodynamic Therapies Catharses & Labeling Feelings n Corrective Emotional Experiences n Insight and Working Through n Learning Coping Techniques n Development of Internal Structure n Other variables n

Insight Oriented Therapies Form of therapy most associated w/psychodynamic approach n Best for children with internalizing difficulties (most often recommended) n n Anxiety • Trauma specifically n Depression

Insight Oriented Therapies Use play and interpretation to work through internal conflicts n Conflict resolution is the goal n Child must: n Trust adults n Have some psychological mindedness n Use play effectively n

Structure-Building Approaches Best for children with problems in relationships (esp. with primary caregivers) n Goal is to help child separate and individuate from the parent n n n Object relations theory Empathy is the focus rather than interpretation

Object Representations n The child must invest in the mental representation of the loved external object n Mental representation of primary caregiver

Object Representations: Provide a feeling of safety n Establish internal regulatory functions n Promote ego autonomy n Serve as a model for character formation n Promote superego development n Provide an ego ideal n Enforce resolution of Oedipal wishes n

Supportive Approaches n n Best for externalizing problems These children have not developed ability to delay gratification and have trouble empathizing with others n n Viewed as a developmental problem! Children recommended for this treatment are characterized as: n n n Egocentric Demonstrate an absence of shame and guilt Impaired ability to empathize with others

Supportive Approaches n Treatment focuses on problem solving and building coping skills n For example, role-play how to handle teasing at school n Focus is on the present not the past n Generally, supportive psychodynamic treatment is not the treatment of choice (CBT approaches much better)

Play as Therapy n Play helps: Foster communication and a relationship between child and therapist n Serve as a vehicle for change n n During play, therapist would use other techniques such as labeling, empathizing, and interpreting

Stages of Play Initial period of nonengagement n Early phase of affective engagement n Emergence of central fantasies n Period of working through n

Initial Period of Nonengagement n Setting the stage Setting expectations n Structure n limits n n Meaningful play developed Sometimes more structure n Sometimes less structure n

Early phase of Affective Engagement Child becomes attached to both process and therapist n “regression in the service of the ego” n Play becomes more open as child masters anxiety/conflicts n

Emergence of Central Fantasies Repetitive Play to deal with past traumatic situations n New solutions played out n

Period of Working Through This period is necessary for a series of interpretations n Symptoms are discussed in different contexts n

Why is play so important? n Play helps children develop in a number of ways Cognitive development—expands vocabulary, helps child develop cognitive flexibility, link objects with actions n Emotional development—helps child resolve conflicts, allows child to freely express and deal with emotions n

Does it work? n Generally, these approaches have not been well-tested Focus on more general goals n Too long term n Not well specified n n Other approaches have been found to be effective for internalizing and externalizing problems

The future of psychodynamic approaches Moving towards shorter treatment approaches n Integrating psychodynamic approaches with other orientations n More focused approaches n Focusing on specific populations and new treatment settings n

Shorter Treatment Approaches/Focused Approaches n n n 6 -12 sessions Necessary (HMO restrictions) Some evidence to suggest time-limited psychotherapy is just as effective as longterm psychotherapy “focal therapy” Brief forms more appropriate who have transient regressions, mild problems with age-appropriate behaviors, acute phobias

Specific Populations in New Settings In schools n In Hospitals n With Abuse Populations n

Interpersonal Theory n n Focus on the importance of interpersonal relationships in determining behavior and psychopathology Harry Sullivan, Adolf Meyer (1950 s) Sullivan (1940): personality is: “the relatively enduring pattern of recurrent interpersonal situations which characterize a human life” (p. xi) Now have manualized treatments

Interpersonal Theory Although childhood experiences are important, IPT regards current relationships as more important n Family systems theories are also based on IPT n Family relationships are interdependent n Family systems tend to maintain a certain structure or homeostasis n

Interpersonal Theory n n n IPT does not necessarily assert that psychopathology arises from impaired relationships But, problems are manifested in these relationships Research has supported this idea n n n Individuals with depression have less supportive relationships Individuals with other problems (e. g. , alcohol abuse) more frequently have marital difficulties Risk of relapse in depression and schizophrenia increases when patients live with critical, negative family members

Interpersonal Therapy n n n Originally developed by Klerman & Weissman for treatment of depression Therapist must actively gather information about a patient’s interpersonal interactions and relationships Overall, therapist takes a more active, supportive approach Usually brief in length Educate patient about nature of depression

IPT is good for: Acute treatment for symptom removal n Prevention of relapse/recurrence n Correction of secondary consequences of depression n Also used for Bulimia Nervosa n Often used in combination with medication n

Interpersonal Therapy n Major goal of treatment= change interpersonal functioning by encouraging: n n More effective communication Emotional expression Increased understanding of behavior in interpersonal settings IPT assumes that by improving relationships, symptoms and the patient’s life in general will improve

IPT Therapists Must be able to maintain optimism n Must be able to adhere to treatment protocol n Must be comfortable with the medical model n Must have a good social support network n Must be satisfied with discrete gains n

IPT for depression n A negative cycle occurs: The individual has an effect on others n Others have an effect on the individual n n Three phases of treatment n Phase 1: assessment and evaluation • Diagnostic evaluation for depression • Symptom Review • Education about depression • Assessment of interpersonal relationships • Interpersonal Inventory • The Sick Role

IPT for depression n Phase 2: n Which interpersonal problem characterizes the patient? • • n Grief Interpersonal role dispute Role transitions Interpersonal deficits Therapist uses specific techniques designed to help the patient work through these problems

IPT for depression n Phase 3: n Consolidation • Helps patients recognize and counter symptoms of depression • Prevents relapse n Special considerations in termination

IPT and Adolescent Depression Brief treatment useful with adolescents n Modifications of IPT for adolescents include: n Flexibility in timing/spacing of sessions n Telephone contact n Therapist may have active role outside of therapy n Specific focus on single parent families n

Does it work? Unlike other psychodynamic approaches, IPT has empirical support n When compared with CBT and medication and supportive therapy, IPT was just as effective n Has also been empirically supported in adolescents n

Case Example n The Adolescent who was frozen with grief