In this essay I am going to examine the main theories of psychodynamic approaches and evaluate the views that I have learned from it. I will be using examples of client work and reflecting how psychodynamic approaches can be incorporated into the integrated model and how this has given me more knowledge using this theory with clients.
How the mind and past events in life can control our emotions and actions today is probably the main stay of psychodynamics. Freud (1923) came to see that many of the problems clients suffered, was the result of mental processes that were hidden to them in the unconscious region of the human mind.
“The importance of the unconscious for Freud makes it one of the principal hypotheses of psychodynamic work” (Jacobs, Pg.12. 2009).
The role of the unconscious is a vital concept of psychodynamic theory. The talking therapy is just one aspect of Freud’s original work, although there are several other ideas which I will look at and reflect on them and how they have informed my integrated model of practice. Freud (1923) suggested that the human personality is made up of three systems, the id, ego and superego. The id and its self-gratification operate on pure pleasure, the ego which tries to find a healthy balance between the id and superego and the superego which pushes for perfectionism which in turn can lead to depression and other psychological problems.
“These three areas of personality interact with one another as a means of regulating an individual’s behaviour”. (Hough, Pg. 79. 2014)
Reflecting on this concept and using supervision, I realise that a client I worked with previously was existing in a life full of guilt and anxiety. She was ashamed of what people would think of her so was striving to be the best she could be thus becoming depressed and anxious in the process. She told me there were days where she refused to leave her bed or engage with anyone. This seemed to stem from being controlled by her parents at a young age and by her partner now who told her that she was useless, and this generated guilt inside her. She looked upon him as being an authority figure as she strived for perfectionism for him and society.
Integrating the three structures of personality is dependent on this balance and a precise perception of the external reality. Anxiety and guilt come when there is an imbalance of all three elements and this has led my client creating defence mechanisms which were suppressed in her unconscious mind and has caused a disturbance in her mental health. Freud believed that defence mechanisms operate at an unconscious level and we all use them occasionally.
“A great deal of our inner life is designed to protect us from anxiety, guilt, and shame, and the defence mechanisms we use do so are often seriously maladaptive”. (Kahn, Pg.204, 2002)
This client I found use humour which we explored together, and she said was a barrier she used against the painful experience she was suffering so no one would know the way she was feeling. Another defence mechanism we explored was projection which I found was a result of the lack of knowledge of her own feelings as she was in denial. She used this to project what she felt onto others which helped in the refusal to accept the painful reality as if it did not exist for her.
Freud talked about the superego within our personality and my client was very much controlled by this aspect of her personality. I found this client had been supressed in some way which was linked to her unconscious process with massive influence from her childhood. This client was able to identify parts of her childhood that repressed a part of her who she felt she should be. Working with this client psychodynamically, helped her feel and say what she knew but wasn’t aware of it.
Carl Jung (1875-1961) talked about archetypes and how they can be opposing types. Jung described four in detail which are as follows: the persona, the anima and animus, the shadow and the self. The two that stands out for my client is the persona versus the self. The persona was part of herself that she was presenting to society and how people expected her to be.
“This is an image of how we think we should appear, and it is based on convention and defined largely by the way other people expect us to be”. (Hough, Pg.114, 2014)
This caused her to feel the way she did but coming to counselling has helped her to explore this negative part of her archetype thus leading her to feel more balanced and at one with herself. In time through the therapeutic process, my client was living her life as the real self instead of behind the mask that she was wearing. Rogers believed that for a person to achieve self-actualization, they must be in a state of congruence. This is achieved when a person’s ideal self is congruent with their actual behaviour and self-image.
Reflecting on this client, I believe psychodynamic approaches were introduced into the integrated model of practice by starting with Rogers’s core conditions which is pretty much the core foundation of building trust in the earlier stage of counselling. Psychodynamic can help create a space where a client can be creative to express parts that they would fear to say otherwise as it focuses on the cause of the problem. Gestalts theory of the empty chair can help clients identify with how it would look like to say and feel the things they want. I believe that once this was achieved, positive thinking can be practised to remember what has been unlocked using cognitive behaviour therapy which focuses on the symptoms.
Freud (1905) also developed the psychosexual stages of development and this theory was very deterministic in terms of childhood experiences and how it affects us in later years. Freud’s ego theory ties into the psychosexual stages in terms of personality growth and when we develop all three personalities. Ego, with us from birth, demands that our needs are met, so if a child isn’t soothed or nourished at an early age, this can be linked to having potential fixations later in life. Freud proposed that theses stages in childhood take place in order starting with oral, anal, phallic, latency and genital.
This brings me to a client that had an eating disorder and looking back on her childhood that she had repressed for years, it became apparent that her childhood was very traumatic for her. Her mother was an alcoholic and when food and love are closely linked to infancy, her early memories of these were negative. This stage according to Freud, is the oral stage. This could have been the connection between infancy and adulthood and it has manifested through her eating disorder and as she said it was more evident through times of stress and unhappiness. Working psychodynamically with this client was significantly beneficial as she found it hard to articulate her feelings as she didn’t understand them.
Freud also talked about transference and countertransference which is the transference of feeling between client and counsellor which can be either positive or negative. These feelings stem from childhood emotional responses to parents or other adults in authority and are not based on any real relationship between counsellor and client. These feelings operate at an unconscious level and it can become evident of the clients early emotional life to be seen clearly in the counselling process. By seeing this, the counsellor can help the client relate current relationship styles to earlier one that has been problematic for the client.
Although this is only a few of Freud’s theory, there were other theorists that attracted my attention. John Bowlby spent a lot of time on the theory of attachment and thought that earlier experiences in childhood have an important influence on development and how we behaved later in life. Our earlier attachment styles are established in childhood through the parent child relationship.
“After the first year the attachment behaviour of an infant can already be classified as secure, insecure or disorganized/disoriented”. (Krumwiede,Pg.3, 2001)
Donald Winnicott is another inspiration for my personal and professional growth. True self and false self are theories introduced into psychoanalysis in 1960 and he believed that we need to help children regulate their emotions by allowing them to feel angry. This is to provide a care base where there is a non-threating behaviour from a child being able to express themselves. Saying and promoting what’s perceived as good or bad behaviour blocks a child’s ego, which supresses the psyche and blocks creativity.
Finally, I am going to look at current research into psychodynamic approaches and will be taking examples from recent evidence from high quality outcome studies.
Jessica Yakeley is a Consultant Psychiatrist in Forensic Psychotherapy and Peter Hobson is a Professor of Developmental Psychopathology. In 2014, they published results of the research into psychodynamic methods. This shows the effectiveness of psychodynamic approaches in both short term and long-term therapy and shows studies addressing psychodynamic psychotherapy for specific mental conditions.
A total of 39 randomised control trials were found which demonstrated that psychodynamic therapy is effective in major depressive disorder, social anxiety disorder, borderline personality disorders, somatoform pain disorder and anorexia nervosa. It can also be considered as possibly effective in generalized anxiety disorder, panic disorder, complicated grief and substance abuse/dependence. Evidence is lacking for post traumatic stress, bipolar, schizophrenia and obsessive-compulsive disorders. Although this evidence shows that psychodynamic therapy is possibly effective in a wide range of common mental disorders, further research is needed for those disorders for which adequate evidence does not yet exist.
It also shows recent evidence from quality outcome studies that “psychodynamic psychotherapy is as effective in the treatment of a range of mental disorders as other psychological treatment modalities such as CBT”. (Yakeley, 2014)
Leichsenring, F. Rabung,S. (2011) researched “the comparative efficacy of long-term psychodynamic psychotherapy (LTPP) in complex mental disorder”.
This therapy lasted a year or 50 sessions and there were 10 studies where 971 patients were included. The conclusion of this study suggested “that LTPP is superior to less intensive forms of psychotherapy in complex mental disorder”. (Leichsenring, Rabung, 2011) LTPP showed higher outcomes in overall effectiveness and it targets problems than shorter forms of psychotherapy. Further research on long term psychotherapy is required, but also on other therapies.
Knekt P, Virtala E, Harkanen T, (2016) compared long time therapy with short time therapy and used 326 outpatients with mood or anxiety disorder that was followed over 10 years. “At the end of the follow up, 74% of all the patients were free from clinically elevated psychiatric symptoms”. (Knekt, Virtala, Harkanen, 2016)
Compared with short term psychodynamic psychotherapy (STPP), LTPP showed greater reductions in symptoms and greater increase in work ability and had a higher remission rate. However, it also showed outpatients that used STPP frequently in comparison with LTPP, the results were rather small due to using STPP regularly.
Jonathan Shedler an American psychologist also carried out his own research into psychodynamic approaches in 2010 which indicated the following. He suggested that considerable research supports the ability and effectiveness of psychodynamic therapy. Clients who received it not only maintained therapeutic gains but continued to improve over time even after treatment ended. Shedler 2010 suggested that “accountability is crucial”, and that there is no evidence that the newer therapies are anymore effective. His findings also revealed that treatment benefits of psychodynamic approaches are as lasting as those reported by other therapists, such as cognitive behavioural therapy.
The message therefore is the evidence in this research demonstrates the effectiveness of psychodynamic approaches is as good as other psychological treatments and the benefits may be long lasting and extends beyond the end of treatment. The problem with this therapy is how long it takes, and most agencies do not cater for this need. Long term psychodynamic therapy may be expensive, and clients may not be able to access it or afford it because of the length and cost of the therapy. Clients’ needs to be dedicated and be able to afford it, although short term counselling is being offered by counsellors trained in this area.
Sinead Mc Gaughey 2061 words