PSYCHODYNAMIC
(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 conscious.
The small amount of
mental activity we
know about.
Thoughts
Perceptions
The preconscious.
Things we could be
aware of if we
wanted or tried.
Memories
Stored knowledge
Bad
The unconscious.
Things we are
unaware of and can
not become aware
of.
Worse
Really Bad
Fears
Unacceptable
desires
Violent motives
Irrational wishes
Immoral urges
Selfish needs
Shameful
experiences
Traumatic
experiences
Freud: Personality structure
EGO:
Conscious
Secondary Process
Memory & Intellect
Rational Thought
Language
Ego functions (Bellak)
Suppression
Repression
PRE-CONSCIOUS: (Superego, morality, shame, guilt, remorse)
ID:
Defense Mechanisms
Unconscious needs
Dreams, free Association
Pleasure seeking
Projective tests
Libidinal & Aggressive Drives
Primary Process
Symbols
Conflicts & Fixations
From Cole, M. Applied theories in occupational therapy: a practical approach instructor's manual. Online document, http://www.efacultylounge.com,
based on Cole, M. (2008). Applied theories in occupational therapy: a practical approach. Thorofare, NJ: SLACK Incorporated.
The Psyche
Id:
Ego:
Superego:
Instincts
Reality
Morality
Healthy Psyche
OK Guys – I’m in charge.
Anything you want has to go
through me.
OK.
OK.
Ego
Id
Superego
Neurotic Psyche
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<
Superego
Id
Ego
Psychotic Psyche
Food! Drink!..........
NOW!
Who turned
out the
lights?
Id
Ego
Superego
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: 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
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, antisocial, 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.