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Relational Psychotherapy -recent advances in psychodynamic psychotherapy and applications

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This presentation is a summary of recent advances and focus on a review on what works in psychotherapy followed by some concepts of object relations effective in clinical work and a discussion on Bion and group psychotherapy – PowerPoint PPT presentation

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Title: Relational Psychotherapy -recent advances in psychodynamic psychotherapy and applications


1
Psychoanalytic Psychotherapy Recent Trends
Application
  • Dr Douglas Kong
  • Retired Consultant Psychiatrist
  • dsgkong_at_gmail.com

2
Topics to be covered today
  • What works in psychotherapy
  • Trend towards relational brief account of
    Object Relations
  • Group applications of Bions theory

3
Freudian Theory 2 aspects
  • The psychic energy aspects
  • The instincts, drives, motives, pleasure
    principle
  • Psychic determinism, sex as biological
  • The psychological aspects
  • The interpersonal aspects, oedipus complex
  • The structural theory
  • Psychological development, aggression

4
Psychotherapy integration
  • From editor of Psychotherapy, 2004-2010 Charles
    J. Gelso
  • 1. Integration of techniques and therapeutic
    relationships
  • 2. Increasing focus on theoretical integration
  • 3. Increasing efforts on research-practice
    integration
  • 4. Increases in more specific integrative reviews
  • 5. Integration of biological, neuroscience
    understandings
  • 6. Integration of diversity and cultural
    integration

5
Empathy research
  • Truax Carkhuff (1965) Empathy than theoretical
    orientation
  • Kohut Introspection, Empathy
  • Martin Hoffman developmental aspects of Empathy
  • Low-empathy and confrontational counselling
    toxic
  • Higher drop-out, higher relapse rates, weaker
    therapeutic alliance and less client change
  • Empathic relationships seems to be client
    specific, session specific
  • Empathy an important component in Therapeutic
    Alliance

6
Empathy and psychotherapy
  • Empathy related to Therapeutic Alliance therapy
    outcome
  • Recognized to have cognitive, affective,
    behavioural and physiological components
  • Positive regard, warmth, congruence,
    unconditional acceptance and psychological
    support
  • Lack of empathy antisocial, narcissistic and
    borderline
  • Empathy meets the narcissistic
  • Empathy vs rebuke

7
Unconditional acceptance
  • Freud vs Rogers
  • DBT - dialectical behavioural therapy
  • Thesis borderline disruptive behaviours
  • Anti thesis new adaptive behaviours
  • Synthesis movement towards new adaptive
    behaviours
  • NLP pattern interrupt
  • Carrying the logic of a thought/behaviour towards
    its logical conclusion
  • Showing its absurdity and so force the change
  • Aversive conditioning for smoking cessation
  • Motivational Interviewing
  • Rolling with the resistance
  • Show the way to handle Resistance

8
Relational emphasis
  • Relational turn arises from several influences
  • advances in philosophy
  • psychology and Sociology
  • Neuroscience social relationships
  • Contribute to integration of psychotherapy
    theory, techniques
  • Includes interpersonal psychoanalysis, object
    relations theory, self psychology, feminist and
    postmodern thinking, attachment theory and other
    related approaches

9
Relational psychoanalysis and Relational
psychotherapy
  • Therapist and patient mutually influence one
    another
  • conscious/unconscious
  • Interactions are enactments of repetitive
    relational patterns
  • Enactments can be destructive but can transformed
    into constructive patterns
  • Therapy is the repair of destructive patterns by
    reflection and affective learning
  • Therapist attend to and reflect on transactions
    within the therapeutic relationship
  • Interventions from different approaches
    compatible
  • the co-creation of the therapeutic relationship

10
Intersubjectivity
  • Used in philosophy, psychology, sociology, and
    anthropology
  • Represent the psychological relation between
    people
  • Agreement, common sense, shared divergence
  • In psychoanalysis, first used by Daniel Stern,
    child analyst
  • Referred to interrelationships of subjective
    minds
  • Developed into relational psychoanalysis
  • Intersubjectivity systems theory (Atwood,
    Stolorow, Orange)
  • What does co-creation means in therapy? 2 experts

11
Energy aspects of Freudian theory
  • Economy of drives and defence mechanisms
  • Currently transformed into Conflict Theory and
    dispenses with the id-ego-superego structure (eg
    Brenner, Abend Arlow)
  • Affinity between psychic energy and qi of
    Chinese culture, Prana of Indian culture
  • Has a stoic connotation which appeals to some
    people
  • Goal is the control and containment of energy
  • Similarities to Buddhist nirvana, monistic ideals
    eg Spinoza, Leibniz
  • In practice, emphasis on meditation, mindfulness
    etc
  • Non-dual consciousness psychotherapy

12
Trends towards brief therapy
  • Against long term therapy funding options
    insurance, self
  • Effectiveness of modern psychopharmacology
  • Economic milieu expectations of fairly rapid
    outcomes
  • Neuroscience pathways conveying regulatory
    processes are distinct from pathways conveying
    survival (negative) processes
  • Recollection of negative memories activate
    (reinforce) negative processes
  • Positive psychology, coaching seems to get fast
    results
  • Psychoanalysis- Good feelings book by Salman
    Akhtar

13
Theoretical Orientation and Process Skills
  • Microskills of counselling
  • Reflecting and summarizing
  • Reflection and summary is akin to
  • psychoanalytic interpretation
  • Observing and giving meaning to what is observed
  • Theory serves as a compass
  • Theory serves as a road-map for therapy
  • Psychotherapy is worth it

14
Advances in psychoanalytic thinking
  • Convergence in analytic thinking esp in ORT
    theorists
  • Integration among those with Object Relations
    Therapy
  • Stephen Mitchell and those after him
  • Recent trends of integrating
  • My own personal development
  • Harry Guntrip
  • Ronald Fairbairn (David Scharff)
  • Melanie Klein,
  • Attachment Theory
  • Group analysis

15
ORT Theorists overview
  • The social schools of Karen Horney, Eric Fromm,
    Harry Stack Sullivan
  • The British Schools of Klein, Fairbairn,
    Winnicott, Bowlby, Guntrip
  • Bowlby and Ainsworth Attachment Theory and
    Patterns of attachment
  • Kohuts self psychology
  • Bions group explorations

16
Object Relations Basics
  • Internal Objects of the Internal World
  • Internal representation
  • Psychological and impression of persons
    (introjected)
  • Allows self to make sense of external world
  • Relate to external object with the internalized
    impressions
  • External objects of the Real World
  • Real world of people, events and places
  • Object constancy
  • Holding environment (Kotani, 1999, Safe Space)
  • Growth and development in concentric circles
  • Mother and child
  • Mother, father and child

17
On 2 levels at the same timeKleinian 2 positions
  • Paranoid Schizoid Position
  • Splitting
  • Projection and introjection
  • Persecutory or supportive parental figures
  • Depressive position
  • Integration of splits
  • Acknowledgement of loss
  • Golden treasures of good objects
  • Rogerian learning (as popularized by Burdett)
  • Protected mode
  • Learning mode

18
Projective Identification
  • Splitting into good and bad objects (libidinal
    and antilibidinal)
  • projecting the bad part onto the external object
    (mother)
  • Experience the external object as persecutory
  • With support and love from the external object,
    internalize good object
  • Child feel secure and integrated
  • Child able to project good parts onto external
    object as well
  • When good external objects are lacking or
    deficient, psychopathology arises
  • Repair consisting of provision of good objects by
    the therapist

19
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20
Caregiver/Therapist
Child/Client
21
Affect bridge from present distress to past
conflict
  • Ask how the client feels as he experience current
    conflicts
  • Using that feeling, ask for episodes in past when
    he experiences such feelings
  • Ask him to describe past episode
  • Get him to re-experience feelings he originally
    had
  • Repeated reflection may yield further episodes
    from the distant past

22
Containment and container
  • Not just containing the emotional rubbish of
    client
  • Container has a transforming function
  • Child internalize soothing, comforting
    (parenting) function
  • When child is unable to use external object as
    container
  • Child contains within himself inhibited, tense,
    bursting

23
Safe Space (Kotani)
24
Reciprocity (Safe Space)
  • A state of attunement, calm, and security
  • Reparations, restitution and reconciliation
  • Pleasantly lost in thoughts and imagination, a
    dream, fantasy
  • Depressive position where the loss is now over
  • Perfect bonding with external object
  • Called reverie, reciprocal enjoyment of both
    external object and child

25
Attachment Theory Psychotherapy
  • Extension of Object Relations
  • Object Relations Intrapersonal
  • Attachment Theory- Interpersonal
  • Attachment issues Anxiety and Loss
  • Ainsworths pattern identified basis for
    intervention
  • Assessments for Adult Attachment
  • Patterns of relating
  • Compulsive self-reliance
  • Compulsive care giving
  • Compulsive care seeking
  • Angry withdrawal

26
What must therapists do
  • Corrective emotional experience (Alexander)
  • Father of psychosomatic medicine
  • Better recovery with short term,
  • better engaged, clear treatment focus
  • Re-parenting (Kohut)
  • Made reparations, integrate (Klein)
  • Secure base (Bowlby)
  • Sense of security facilitates exploration
  • Autobiography competence
  • Second skin (Bick)
  • Attachment behaviours
  • Validated by neuroscience

27
Bion and group psychotherapy
  • Foulkes Anthony Group Psychotherapy
  • Yalom Theory Practice of Group Psychotherapy
  • Bion Experiences in Groups
  • Bions leaderless group
  • Bions theory of thinking, alpha function
  • Alpha and beta elements
  • -L and K functions
  • Bion and dreaming
  • unconscious processing of emotional content

28
Different kind of groups
  • Small groups, family group(up to 15)
  • -transference phenomena
  • Median groups social group (15 to 25)
  • Transference phenomena disappearing
  • Non transference phenomena eg mirroring,
    resonance,
  • ego-self training in action
  • Archetypal representations
  • Large groups (25 and above)
  • Philogenetic regression, psychotic phenomena
  • Masses
  • Primordial level of the Foulkesian matrix
  • Archetypal representations of the collective
    unconscious

29
Bions basic assumption groups
  • Basic Assumptions - means of allaying anxiety
  • Dependency
  • Flight/fight
  • pairing
  • Work Groups- productive/creative work
  • Traumatized groups
  • 4th basic assumption incohesion
  • Aggregation (crustacean)
  • Massification ( amoeboid)

30
Large group experiences
  • Definition
  • Small group up to 15
  • Median group 15 tp 25
  • Large group 25 or more
  • Group intervention in businesses and
  • organizations, community
  • Group therapists as organizational consultants
  • Community intervention
  • Social dreaming
  • System Centred Theory group work
  • Use of subgrouping
  • Systemic explorations

31
What works in MI?from Prof W. Miller,
Motivational Interviewing
  • Counsellors must be empathetic
  • Counsellors must NOT be confrontational
    (Acceptance)
  • Clients Change Talk makes the difference
    (Engaged)
  • Counsellors must be skilled in reinforcing Change
    Talk Reciprocity)
  • It is all in the relationship between counsellor
    and client
  • Two most important factor RELATIONSHIP and
    TECHNIQUES

32
Implications for current clinical practice
  • Relational emphasis
  • Intersubjective
  • Use more than one roadmap
  • For non-therapist, pay attention to the person

33
Dr Douglas Kong dsgkong_at_gmail.com
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