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Psychodynamic Theory and Practice

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... required and the type of relationship too (Clarkson 1995) ... Combined with Kelly's Construct Theory and CBT. An advantage of combining methods thoughtfully ... – PowerPoint PPT presentation

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Title: Psychodynamic Theory and Practice


1
  • Psychodynamic Theory and Practice
  • Course COP020M01OA
  • Postgraduate Diploma in the Practice of
    Counselling Psychology/MSc
  • School of Psychology and Therapeutic Studies,
    Whitelands College.

2
Brief Psychodynamic Models outline
  • History of brief psychodynamic work
  • The dynamics of the work
  • Why now?
  • Cons
  • Pros
  • A model in a little detail
  • Safeguards in brief work

3
HISTORY
4
Brief therapy is not new
  • Freud ( Mahler in one session), Klein
  • Malan thinks Freud took a wrong turn when
    increased resistance by client met with increased
    passivity from therapist
  • By 1920 Rank and Farenci trying to shorten
    therapy by activating transference
  • Alexander and French (1946) Therapist active from
    the start- the here and now really important-
    corrective emotional experience

5
Balint, David Malan and others (1950s)
  • Working with Michael Balint onThe doctor, his
    patient and his illness
  • Began to treat really ill people briefly at
    Tavistock cf.. Previous cases of treating only
    recent onset in basically healthy patients
  • Limited sessions. Mann (12), Sifneos 12-20 Danvaloo

6
Brief Psychodynamic therapy with...
  • Mann worked from the beginning with separation.
    Chronic and present pain
  • Sifneos worked in Boston with middle class
    patients. Worked only with Oedipal issues
  • Danvaloo- v. disturbed people- highly resistant.
    Very confrontational. Good follow-up

7
Something in common the working alliance and the
corrective emotional experience
  • Working with the transference
  • Triangle of conflict
  • Triangle of Persons
  • Keep revising, reviewing, using learning
  • High level of therapist activity
  • Diagnosis is prognosis

8
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9
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10
High Level of Interpretation (Description)
  • Based in Ego Psychology
  • Conflict, unconscious motivation, repetition of
    maladaptive behaviour
  • Need to decide fairly early on as to what the
    focus is
  • Free association be used for specific issues
  • Emphasis on interpretation, transference, counter
    transference

11
Elton Wilson(2000) Brief therapy is a state of
mind
  • focussed
  • contractually-committed
  • time -conscious

12
Selection of Clients
  • High motivation for change
  • At least one meaningful relationship
  • Able to separate
  • Psychologically- minded
  • Danvaloo says that some people need cognitive
    restructuring before they are ready for brief
    psychodynamic work.

13
WHY NOW?
  • Release from orthodoxy on death of Freud (Budman
    and Gurman 1988)
  • Pressure from Insurance Companies, Cost of NHS
  • No overwhelming evidence for the efficacy of
    long-term therapy

14
Some research indicators...
  • Howard et al (1986) 62 most effect in the first
    13 sessions ( so called dose effect)
  • Mann (1973) Long-term therapy is a refusal to
    accept responsibility for a painful life.
  • Pressure from economics, realism, research
    possibilities and clinical issues

15
CONS
16
Superficiality argument the solution-based
approach
  • insight is necessary for changes
  • symptoms have deep underlying causes
  • removal of symptoms may be useless or dangerous
  • Symptoms serve functions
  • Must wait for client to overcome defences
  • Brief interventions dont last
  • They focus on pathology or deficit

17
More objections
  • Flight into Health (Feltham 1997)
  • Argument for hard-earned conceptual gain
    (Gustafson 1986)
  • Therapy takes as long as it takes. It is a
    slow-cooker not a Microwave (Karuso 1992)
  • Short-changes the client (Rowan 1993)

18
Some clinical examples of contraindications to
brief therapy
  • May be inappropriate to ontological anxiety
    e.g.my professional client who wandered around
    a long time in the holding environment before he
    could reach his own sense of meaninglessness
    (The worried well?)
  • e.g. Where safe reparative relationship required.
    My sexually abused client who had previously had
    abortive therapy.

19
PROS
20
On the other hand...
  • Ryle (1991)positively recommends short term work
    in the NHS
  • De- Shazer (1985) claims that therapy can and
    should be done quicker.

21
More pros...
  • What about for serious conditions Molnos (1995)
    BPD discourages timelessness
  • Short therapy contributes to upstream work in
    organizations (Carroll 1997)
  • Short Therapy respects the kind of intervention
    required and the type of relationship too
    (Clarkson 1995)
  • Accords with Post-modernist ideas of no
    monoliths see narrative therapy e.g in PTSD (see
    Rose et al 2000 Cochrane Collaborative Review)

22
And yet more pros
  • Mohamed and Smith (1996) Clients find the
    temporal structure reassuring
  • Striano (1988) Brief therapy does less damage
  • Malan (1976) Ending date is important but not the
    number of sessions
  • Holmes and Lindley (1989) Brief therapy may be
    more accessible to working class people

23
A MODEL IN A LITTLE DETAIL
24
Cognitive Analytic Therapy
  • A bold attempt to achieve brief, truly
    integrative (c.f. eclectic) psychodynamic and
    cognitive therapy.
  • Instigator Anthony Ryle, St Thomass Hospital
  • Exposure to epidemiological research high
    prevalence, persistence and personal cost of
    common neuroses.

25
A new insight?
  • Personal neurosis inseparably bound up in the
    social context and problems of living for clients
  • Also inextricably bound up in the family
    structure and in personal relationships.
  • An attempt to integrate psychoanalytic
    formulations into operationally reliable
    descriptions or measures.

26
Neurotic phenomena
  • Traps negative assumptions generate acts produce
    consequences which reinforce the assumptions
  • Dilemmas polarised alternatives (false
    dichotomies)
  • Snags appropriate goals/roles are abandoned
    either without reference to others, or based on
    the assumption that they would be disapproved of.

27
The treatment Plan
  • ReformulationFirst 4 sessions devoted to
    therapeutic relationship and finding the target
    problem and Target Problem Procedures. Agree in
    writing what the TP is.
  • The next eight sessions spent on recognizing and
    monitoring Target Problem Procedures. Assisted by
    focussed diary-keeping

28
Reformulation (see your handout on Elaine)
  • Designed to generate accurate descriptions and
    crucial re-definitions of clients procedures,
    offering a new tool for self-reflection
  • Work towards an ending all the time
  • Sessions end with a goodbye letter
  • New understanding/new experience and new acts.

29
The psychotherapy file is a potent aid to
enlisting the client to active participation
  • You have been given a copy of this. Fill it in as
    best you can on behalf of a client who is causing
    you concern at the moment
  • We will use it for paired work next week to help
    you to unravel the psychodynamic element in this
    well integrated model.

30
Integration around...
  • Value given to object relations offers a link
    between infantile development, personality
    structure and pattern of relationships
  • Crucial importance of therapeutic relationship
    i.e. transference and countertransference
  • Combined with Kellys Construct Theory and CBT

31
An advantage of combining methods thoughtfully
  • Believes transference issues thrown up more
    rapidly if the therapist is active
  • The Procedural Sequence Model in CAT
  • Snags, traps and dilemmas are examples of
    procedures
  • The sequence in which these procedures are
    employed is crucial

32
An address
  • Association for Cognitive Analytic Therapy
  • 3rd Floor, South Wing, Division of Academic
    Psychiatry
  • St Thomass Hospital
  • Lambeth Palace Road
  • LONDON
  • SE1 7EH
  • Website www.acat.org.uk

33
SOME SAFEGUARDS
34
Ready for you to practice after the break
  • 1.Awareness of the ending needs to be present
    right from the start.
  • 2. Level of transferential interpretation needs
    to be appropriate to the client but also to the
    length of the therapy
  • 3.When using a history the therapist needs to be
    confident that there is time to work though new
    awarenesses.

35
And finally...
  • The emphasis on the use of breaks, lateness,
    absences, payments in psychodynamic work applies
    also to endings.
  • The good enough ending may be the most important
  • This does not necessarily mean it has to feel
  • good to you
  • .

36
And finally
  • 4. The emphasis on the use of breaks, lateness,
    absences, payments in psychodynamic work applies
    also in brief therapy
  • The good enough ending may be the most important
    part of the therapy to the client. This does not
    mean that it necessarily feels good to you
  • 5. It is inadvisable to enter exploration into
    new material in the last session
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