History of Psychiatry - Franz G Alexander and Sheldon T Selesnick - Notes on Dynamic Psychotherapy

Franz G. Alexander and Sheldon T. Selesnick. The History of Psychiatry: An Evaluation of Psychiatric Thought and Practice from Prehistoric Times to the Present, New York: Harper & Row, 1966 - page 321 - 333 

Notes on the essential psychodynamic/psychoanalytical principles that form the foundation of the past 100 years of psychodynamic treatments.

 The guiding principles of psychoanalytic treatment that were formulated by Freud in the early part of this century have undergone few changes since its beginning. During psychoanalytical, psychodynamic treatment the unconscious, which is where all the repressed material is located becomes conscious.  That is to say, the unconscious becomes conscious.  The person becomes aware of unconscious impulses, instincts, and memories and with the help of the therapist can coordinate and integrate them into consciousness.  His past becomes present in the therapy. This means that all future conscious thoughts that will contain these previously unconscious elements are now conscious to the individual, and he can begin to coordinate and integrate this new conscious material into the present. Many behaviors are no longer driven merely by unconscious impulses driven by internal conflicts, otherwise known as neurotic focuses.   The patient resists recognizing unconscious content. Overcoming this resistance is the primary technical barrier to successful treatment. As a result, the newly emerging integrated ego can modify previously unconscious impulses and include them in conscious voluntary behaviour without any internal conflict. His conscious mind is now at peace with his unconscious mind. This is known as integration or simply ‘peace of mind’. This transformation of mind was later seen by Jung and others as the basis of “a religious experience” which is a well-established fact in all of the major religions.

 

The mobilization of unconscious material leading it to become conscious is achieved mainly by the patient's emotional, and interpersonal experience in the therapeutic situation, in the room with the therapist.  He develops transference feelings with the therapist the repletion – trauma re-enactment of interpersonal attitudes and behavious that characterize his childish feelings about his parents or other significant people in his life.  This process of transferring these feelings to the therapist is achieved by the therapist encouraging the patient to express themselves as freely as he can during each session.

 

 The original neurosis of the patient, which is based on his childhood experiences, is thus transformed into an artificial ‘transference neurosis’ which is a less intensive repetition of the patient’s ‘infantile neurosis’ that is to say his early unresolved conflict.  The resolution of these repeated, reexperienced feelings and behavior, the resolution of the transference neurosis becomes the aim of treatment. There is little disagreement about these fundamentals of psychoanalytical treatment. Most controversies pertain primarily to the technical means by which the transference of these neuroses, these conflicted unresolved past traumas, are brought to the surface and discharged. With these new cognitive insights, the conscious mind is now conscious of the unconscious and begins to break up the neurotic patterns that the person has been suffering from. He begins to experience hope, self-awareness, self-insight and a deeper understanding of his life. Can forgive himself, finally discharging his guilt, as he now understands clearly through his new self-awareness his previous faulty self-narrative. The lies that were told to him and the lies that he told himself, the delusions and illusions are now invalidated. This is now the end of his own self-deception. He now sits on new ground, a new truth upon which to build a new future. In the Christian tradition, for instance, this would be simply called being “Born again”.

 

 

Concerning any psychotherapeutic technique, in general, there are always two main areas of emphasis.  One is on the cognitive system, the intellectual system that forms cognitive insight as a means of breaking up the neurotic patterns. This would include the various types of therapies under the broad category of cognitive therapies. And secondly, the emphasis is on the emotional system, all the feelings and emotional experiences the patient undergoes during treatment. This would come under the broad category of Dynamic Therapies. There are only two operating systems, the cognition system and the affective system (emotional/instinct) system. Dynamic therapies are concerned only with the latter Affective system.

 

 

 ISTDP therapy believes that insight imparted to the patient by the cognitive system has fewer efficacies than insights gained through the emotional system of knowing, through the process of reliving emotionally in the here and now of the therapeutic transference. Some of the main ego defences that dynamic therapy must overcome are all the intellectual defenses such as isolation of affect, rationalization, and intellectualization. The background to these first-line defenses is the other more primitive defenses that drive and sustain the isolation of affect. These would include, splitting, projection, and idealization.

 

 

The goal of therapy is to have a ‘corrective emotional experience’ in that the patient can differentiate between the original conflicts of the past and their reactions to it by various ego defenses that they constructed to maximize their ‘fitness’ in their early relationships and the actual conflicts between the doctor and patient relationship in the transference. This is called the “Past – Present” linkages that are made by the client as more and more unconscious material is processed into the conscious mind.

 

 

The new restruching of the old unresolved conflict in the transference situation becomes possible not only because the intensity of the transference conflict is less than the original conflict but also because the therapist's actual response to the patient’s emotional expression is quite different from the original responses towards the child by the parents.  For instance, the therapist does not react to the patient's expression of hostility by retaliation, reproach or signs of being hurt as the patient would expect the therapist to do because of the transference. By acting in a completely opposite manner the patient is forced to wrestle with the discrepancy of response between the parent in the past that they are used to and the therapist's opposite response with the realization that, the patient's automated defensive responses that were developed in childhood were contextually driven.  The goal is for the patient to become increasingly aware of their own ego development and hence self- identity is rooted in causation. Freud used the term psychological determinism.

 

  The fact that the patient continues to act and feel according to outdated earlier patterns whereas the therapist's reaction conforms to the actual therapeutic situation makes the transference behaviour a kind of one-sided shadowboxing.  This allows the patient to not only understand his neurotic patterns but at the same time to experience intensively the irrationality of his own emotional reactions.  The fact that the therapist's reaction is different from that of the parent, to whose behavior the child adjusted himself as well as a code with his own neurotic reactions, makes it necessary for the patient to abandon and correct these old emotional patterns.  After all, this is precisely one of the ego's basic functions, to adjust to existing external conditions.  As soon as the old neurotic patterns are revealed and brought into consciousness the ego has the opportunity to readjust them to the changed external and internal conditions.

 

 

This contrast between the transference situation in the actual relationship between patient and physician has long been considered an essential therapeutic factor.  In the past present linkage, the patient recognizes that his attitude towards the therapist is rooted in childhood and is not an appropriate reaction to the therapist in the here and now.  The patient recognizes the difference between the ‘archaic fantasy object’.  That is the transference and the real external object’ of the therapist.

 

Countertransference can be either helpful or harmful depending on whether they are different from, or the same as the parental responses that contributed to the patient’s difficulties. It's for this reason, the therapist's success or failure is often entirely dependent upon his own self-awareness as a person himself, as he must, to be therapeutic, respond verbally and nonverbally in a different manner than the client's parents to begin to correct the original neurotic,  often times abusive inter-personal pattern that the clients have always lived with.

 

 

Transference cures occur with the therapist when the patients re-experience intense emotional reactions towards the therapist that had been repressed and unprocessed based on past conflicted relationships that resulted in intensely conflicted feelings in the intrapsychic space. Therapy creates a situation of trauma re-enactment for the patient.  The reason for the shadowboxing towards the therapist comes from the ‘ghosts of the past.  They are reliving the past in the present but this time if a therapeutic alliance is strong enough, they can hang in there in the working relationship and process and discharge those loaded emotions. Inner, internal, intrapsychic, conflicts, traumas, and neurosis, are all discharged, and purged into the interpersonal space, the intersubjective space between therapist and client.

 

 

Freud had originally likened the analyst's role in the treatment as a blank screen.  He felt that the analyst was to keep his neutrality so that the patient could project onto him his unconscious material, as onto a blank screen, of any role example the image of his father or of his mother or any other significant person in the past.  In this way, the patient can reexperience important interpersonal events of this past undisturbed by the personality of the therapist.  It is now generally recognized, however, that in reality the analyst cannot and does not remain a blank screen or an uninvolved intellect, but is perceived by the patient to be a concrete person who reacts to the patient in many different ways.  The key point in counter transference issues is that the therapist must be keenly aware of his own spontaneous feelings towards the patient and try to replace them with an interpersonal climate that is suited to correcting the original neurotic patterns. 

The patient in the transference will see the therapist as a parent, but the therapist must counteract this trend and not allow himself to be pushed into the parental role. The Parentifying Transference must be resolved.  The patient in treatment must learn to understand his own motivations.  This enables him to take over his own self-management, he becomes autonomous, self-aware, and self-determinant for the first time in his life. He no longer simply reacts to situations by the various pleasing behaviours. He becomes the initiator of his actions, self-generated without the need to please others. His ego becomes free at last, freedom found after freedom was lost long ago.

There is always a drop in anxiety/paranoia as it is replaced by trust. Religious communities would call this trust, faith. Once this anxiety is reduced the mind can process material and spontaneous insights begin to occur over time.

A successful therapeutic encounter restarts the arrested emotional/affective system that previous to the therapy had as its foundation the attitudes and values, resulting in dogma and indoctrination that the individual had learned from his parents and other powerfully influential people in his previous life until the acute crisis. His failure to adapt, brought him to a place of pain and dysfunction, wherein he sought help, someone outside the family with an entirely different perspective than the one held collectively and also by the groups' egocentricity/ arrogance and intolerance.

 

 Source – History of Psychiatry – F. Alexander and S. Selesnick – page 321 - 333 Published 1966. I have also taken the liberty to add some of my musings.

I