Class 7: Core Psychodynamic Problems

Question 1

Nomothetic vs. Idiographic Knowledge

Answer 1

• then on next page without header
  
  • We can recognize patterns
  • We can identify problems
  • There are common problems that fit well with a psychodynamic approach
• Nomothetic..bigger
• idiographic…more to individual

Question 2

Core Conflictual Relationship Theme

Answer 2

• Core Conflictual Relationship Theme (CCRT)
  
  • Luborsky and Crits-Cristoph
  • CCRT
    
    • What the patient wanted from the other person (wish)
    • How the other people reacted (response of other/RO)
    • How the patient/”self” reacted to their reactions (response of self/RS)
  • CCRT recurs across relationships, form a pattern or schema

Question 3

Core Psychodynamic Problems

(list them)

Answer 3

• Depression
• Obsessionality
• Fear of abandonment
• Low self-esteem
• Panic anxiety
• Trauma

Question 4

Typical CCRTs

(depression)

(Summers and Barber, 2010, pp 96-97)

Answer 4

• Wish to be loved—>rejected by others—>feel depressed/angry

Question 5

Typical CCRTs

(Obsessionality)

(Summers and Barber, 2010, pp 96-97)

Answer 5

Wish to be in control of emotions & impulses —>others are controlling me—>feel angry/anxious

Question 6

Typical CCRTs

(Fear of abandonment)

(Summers and Barber, 2010, pp 96-97)

Answer 6

Wish to merge/be close —>people are abandoning me—>feel alone, angry

Question 7

Typical CCRTs

(Low self-esteem)

(Summers and Barber, 2010, pp 96-97)

Answer 7

Wish to be taken care of, love, respected, admired

—->not given enough respect, love, admiration —>feel empty and not admired

Question 8

Typical CCRTs

(Panic anxiety)

(Summers and Barber, 2010, pp 96-97)

Answer 8

Wish to be close and loved —>people leave me —>feel loss, fear, anger

Question 9

Typical CCRTs

(Trauma)

(Summers and Barber, 2010, pp 96-97)

Answer 9

Want to trust and be safe —>others violate my trust —->feel afraid and not trusting

Question 10

Depression

(May present as)

Answer 10

• sadness
• loss
• melancholy
• boredom
• frustration
• irritability
• fear, abandonment
• hopelessness

Question 11

Depression

(Subjective experience)

Answer 11

• Feelings of self-criticism
• negativity
  
  • hopelessness
• loss
  
  • death….relationship like divorce…a move

Question 12

Depression

(Theoretical considerations)

Answer 12

• Freud’s “Mourning and Melancholia”
  
  • go from grief to melancholia..which is pathological….loose internal self
• Klein’s Depressive Position (love and hate/frustration co-exist)
  
  • schizoid position
    
    • mom is all good or all bad
    • love and hate split….cant bring them together which results in loss of one or other
• Kohut’s poor self-object
  
  • poor idea of self object
  • limited attachment results in feeling of sadness loss depression

Question 13

Depression Formulation

Answer 13

• Frustration with early attachment leads to anger and guilt
  
  • instead of expressing anger outward…gets expressed inward…as self criticsm
• Response is to try to connect with idealized others
  
  • constantly comparing to best parts of others “like facebook”
• Idealized others disappoint
• Strengths sabbotaged
  
  • Courage (lack of energy), humanity (ability to engage…social withdrawl), transcendence(apprechiation of beuty in life)

Question 14

Depression Treatment Goals

Answer 14

• Decrease patient’s vulnerability to abandonment
  
  • “Ride out” natural ups and downs of relationships
• Decrease tendency for harsh self-criticism
  
  • Hold on to a more positive sense of self

Question 15

Depression Treatment Techniques

(Phases)

Answer 15

• Phase 1
  
  • Supportive environment + education about depression
  • Behavioral activation
• Phase 2
  
  • Identifying the key themes of (a) abandonment and loss, (b) resentment
  • Increased self-awareness, changing perceptions, trying new behaviors
• Phase 3
  
  • Maintenance, deepening, working through
• Phase 4
  
  • Termination
  • Fear of recurrence

Question 16

Depression: Transference & Countertransference

Answer 16

• Anaclitic (abandonment) depression
  
  • Transference = feeling abandoned
  • Idealize therapist, develop feelings of dependency
  • CT: rescue fantasy (I alone can help the patient through my care and interest
• Introjective (guilty) depression
  
  • Transference tends to take the form of disappointment and anger toward therapist r/t past losses
  • CT: feelings of incompetence (in response to patients’ anger) or feeling sucked dry

Question 17

Obsessionality: Controlling Feelings

Answer 17

• Strong emotions, viewed as inconvenient or even threatening
• OCPD; not OCD
• Theoretical Considerations
  
  • Freud’s Anal stage:
    
    • value in order
      
      • thought over emotion (no evidence)…buy into thoughts will weaken you
    • fixation with ability to let go
    • Id wants relief by dischage and libido stuck….dont let go
  • Ego Psychology: Id/aggression/anger is bad, must be controlled
    
    • internalized superego…
      
      • anger is bad and must be under control
      • desire to control feeling…leads to obsessionality

Question 18

Obsessionality Formulation

Answer 18

• Defenses control feelings/aggression
  
  • Intellectualization
    
    • reliance on cognitive processes
    • control anger and dont get mad at abuser…that they love you and it was their way of showing it….
  • Isolation of affect
    
    • _​_separating thoughts and feelings
      
      • you can feel one way but you have to do whats right
  • Reaction formation
    
    • _​_substituting positive feeling for negative
    • mom who feels agressive impulse to child for loss of freedom and then reacts to extra feeling of love to kid
  • Displacement
    
    • _​_shifting feelings/conflicts from one situation to another
    • kick dog because mad
  • Doing and Undoing
    
    • _​_express something, then take it back—”Just kidding.”
    • think passive agressive….dont really mean that…slipping through of control mechanisms
• Conflict over aggression—guilt
  
  • would much rather not have agression but when do feel guilt
• Control protects against strong negative feelings
• Strengths
  
  • impaired by rigidity and constant control
  • wisdom, knowledge, and humanity (love, kindness….which makes sense bc they are unpredictable)
    
    • in order to be wise…have to be open to curiosity…feeling…cant be curious if have to be worried about what is coming up and having to control it

Question 19

Obsessionality Treatment Goals

Answer 19

• Goals:

1. help patience experience a wider range of emotions
2. increase tolerance and acceptance of range of emotions
3. decrease guilt

• Challenges
  
  • Patient fears loss of control associated with negative emotions, fear of retaliation
  • Patient can experience anger and loss in the treatment relationship

Question 20

Obsessionality: Treatment Techniques

Answer 20

• Therapeutic alliance: bookend interpretations with empathy
  
  • encourage them to conceptualize their prob to give them sense of control
• Psychoeducation: lay out the “rules”
• Help patient recognize and identify feelings
  
  • Mirroring, empathizing, active acceptance (to counter harsh superego
  • Circle back, going just a bit deeper each time
• use empathy

Question 21

Obsessionality: Transference & Countertransference

Answer 21

• Transference
  
  • Patient feels the need to control the therapy and the therapist
  • (in order to manage the negative feelings)
• CT
  
  • Frustration, impatience, boredom (they ruminate), disconnection

Question 22

Fear of Abandonment

Answer 22

• Insecure attachment
• Feelings of vulnerability to separation, abandonment
• Will use desperate strategies to stay connected
• Subjective experience
  
  • Intense feelings of abandonment, chronic anger, physical and psychiatric sxs, alternating good and bad internal representations of others and self, no engaging activities, feelings of emptiness, impulsivity
  • Defenses:
    
    • splitting
      
      • all good or all bad
    • projective identification
      
      • youre just like…
      • de-realization
        
        • loose contact with what is real…they loose touch with that there is also good…

Question 23

Fear of Abandonment: Formulation

Answer 23

• Theoretical Foundation
  
  • Bowlby’s insecure attachment
  • Mahler’s problems in rapprochement phase
    
    • inabliity to adjust
  • Kernberg’s attention to subjective experience of aggression and rage
    
    • Recommended confronting the rage in the transference
  • Patient protects against abandonment by controlling relationships and feelings, keeps others bound to them
  • Splitting allows a sense of goodness to survive
  • May manifest as clinging behavior or rejecting
• Strengths impaired
  
  • humanity
    
    • ability to build relationships, love and kidnness
  • justice

Question 24

Fear of Abandonment: Treatment Goals

Answer 24

• More stable, integrated image of self and other
  
  • Ability to be effective and active
  • Show them you have both good and bad
• Decreased emotional reactivity
  
  • Contain destructive emotions
  • emotions are reactive in nature…with impulsivity..teach to decrease emotion reactivity
• More stable relationships

Question 25

Fear of Abandonment: Techniques

Answer 25

* Therapeutic Alliance * Calmness, patience, consistency * Tolerance of strong affect * Gunderson’s use other relationship to try out new self-perceptions and perceptions of others * Patient to verbalize feelings of loss and anger * Encourage self-soothing * DBT * Coaching support to help with fear of abandonment, help build repertoire of success * Treatment contract re: (un)acceptable behaviors, with clear contingencies * Flexibiilty, availability, responsiveness, within limits

Question 26

Fear of Abandonment: Transference and Countertransference

Answer 26

* _Transference_ * Split * Dependency * _CT_: helplessness, hostility, detachment * Needs to be closely monitored