Social Science ASSIGNMENT 2 - THEORY

Psychodynamic therapy: for many people, including some within the allied mental health professions, the term conjures up the time-worn image of a patient lying on a sofa while the clinician (in this scenario, probably a middle-class, intellectual white male) prompts, “Tell me about your relationship with your mother.” As this stereotype indicates, psychodynamic theory, and its related therapeutic practice, is probably both the best-known and most misunderstood of the approaches used in contemporary clinical social work. This paper attempts to provide a corrective to such misinformation by first discussing the descriptive and prescriptive elements of psychodynamic theory, and then evaluating what recent research reveals about the efficacy of psychodynamic therapies as employed by today’s mental health practitioners in a variety of settings and with diverse populations.

Descriptive Theory

Psychodynamic theory first developed, of course, in the works of Sigmund Freud, and many of Freud’s central theses have filtered into the popular consciousness. Chief among these are drive or instinct theory, topographical theory of the mind, the structural model of the mind, and psychosexual stage theory (Hutchison, 2013). A brief review of these concepts is essential to understanding the roots of the psychodynamic approach. Drive or instinct theory is one of Freud’s major efforts at explaining all human behavior, which he theorized as being motivated by one of two drives, either eros, which is the drive for sexual satisfaction, or Thanatos, the death drive (Hutchinson, 2013). The idea that each individual’s thoughts occur on three distinct planes – the conscious, the preconscious, and the unconscious – is the topographical theory of the mind, and is familiar to many people, although the unconscious and preconscious are often confused. According to Hutchison (2013), “Preconscious thoughts and feelings… can be easily brought to mind” while the unconscious consists of “thoughts, feelings, and desires of which we are not aware but which have a powerful influence on our behavior” (p. 56). Likewise, the Freudian concepts of the id, superego, and ego are often referenced, but for many the specifics may remain hazy. These terms represent the three levels of Freud’s structural model of the mind, which largely corresponds with the topographical theory of the mind. Freud believed the mind consisted of three elements: “the id, which is unconscious and strives for satisfaction of basic instincts; the superego, which is made up of conscience and ideals and is the censor of the id; and the ego, which is the rational part of personality that mediates between the id and the superego” (Hutchsion, 2013, p. 56). Finally, the psychosexual stage theory is Freud’s theory of human development from birth to adulthood. Freud theorized that the major stages of an individual’s development, all of which occur before the child reaches adulthood, were motivated by the drive for pleasure, and as such he characterized each developmental phase according to where pleasure was physically and psychically located: the oral phase from birth to around eighteen months; the anal phase from about eighteen months to age three; the phallic phase from ages three to six; the latency phase, from ages six to eight, during with the child learns repression and self-control; and finally the genital phase, starting in adolescence and characterizing the remainder of the human lifespan (Hutchison, 2013).

Freud’s body of work is large and heterogeneous; he worked and re-worked his theories throughout his career, and thus the tenets of psychodynamic theory even as espoused by their founder can seem conflicting. In the century and change since first being articulated by Freud, psychodynamic theory has been expanded, molded, and corrected by numerous scholars and practitioners, among the best-known of whom are Anna Freud, Carl Jung, Erik Erikson, Melanie Klein, and Heinz Kohut. Arguably it is more accurate to discuss psychodynamic theories, in the plural, as many of the articulations subsequent to Freud’s were developed in response to criticisms of the theory as originally stated. Major criticisms include the identification of masculinist and Euro-centric biases in the theory, and the lack of attention to sexual, class, or racial diversity. Thus psychodynamic theory today is quite a different creature from that first envisioned by Freud, as becomes clear in any discussion of contemporary psychodynamic practice. Ego psychology, self-psychology, and relational theory all developed from psychodynamic theory, and psychodynamic theory overlaps with many aspects of the developmental perspective, in conjunction with which it is often discussed.

Prescriptive Theory

The idea of so-called talk therapy, much lauded and oft-maligned, is the central contribution of psychodynamic theory to the modern mental health field. As Hutchison (2013) states, although psychodynamic practice today is quite diverse, “Practice principles common to all versions of the psychodynamic perspective include the centrality of the professional-client relationship, the curative value of expressing emotional conflicts and understanding past events, and the goals of self-awareness and self-control” (p. 58). While Freud understood the professional-client relationship as integral to therapeutic practice, the concept of what constitutes an ideal version of this relationship has changed considerably during the intervening century. Initially, the clinician was viewed as the authority figure, and was tasked with remaining entirely neutral, not revealing any personal information about him- or herself, and not providing any type of directive intervention. When the client sees the therapist in this way, as a clean slate or blank mask, it allows for transference, the process by which the client transfers his or her past relationships or unresolved conflicts onto the therapist and works these issues out by re-enacting them in the therapeutic environment. Although the idea of transference is still important in psychodynamic therapy, and standards of professional behavior must be strictly adhered to, such blank objectivity is no longer considered the therapeutic gold standard. According to Susan Bliss and Brian Rasmussen (2013), “[C]ontemporary psychodynamic social work is less dogmatic, more flexible and integrative, supported by evidence, more pragmatic, highly attentive to relational needs, less hierarchical and applicable to a wide range of clinical problems with vulnerable populations” (p. 211). Today psychodynamic therapy may be short- or long-term; the clinician is a collaborator rather than an authority; and the client’s emotions and experiences play a central role in therapeutic work.

Recent Research

Mishna, Van Wert, and Asakura (2013) assert that “contemporary psychodynamic theory and practice particularly promotes the following two key principles of social work: (1) emphasis on the therapeutic relationship and (2) the person-in-environment-perspective” (p. 291). By focusing on the person-in-environment, the authors are responding to two of the criticisms often leveled at psychodynamic therapy, which are that (a) this type of therapy lends itself solely to micro, rather than mezzo or macro, level practice and understandings of causality, and (b) that it tends to pathologize clients rather than seeing their “disorders” as social, cultural, or environmental products. Both Mishna, Van Wert, and Asakura (2013) and Bliss and Rasmussen (2013) enumerate many criticisms of psychodynamic theory and its related therapies, several of which I have already touched upon. Perhaps most significant for social work given the emphasis on evidence-based practice is the commonly held belief that the efficacy of psychodynamic interventions is notoriously difficult to demonstrate. Mishna, Van Wert, and Asakura (2013) offer a number of possible explanations for this phenomenon, the most persuasive of which is that psychodynamic therapists and clients often set goals related to improvements in overall quality of life, rather than reduction in symptoms (as in cognitive-behavioral or solution-focused therapies), and that these outcomes are much harder to measure.

Further to this, Hingley (2001) offers a case study of a 45-year-old woman whose narcissistic personality disorder showed measurable improvement in symptoms during a two-year course of psychodynamic therapy, an improvement which Hingley attributes to the ability of the client-therapist relationship to allow the client to replay her problematic relationships through transference and in the process develop healthier defense mechanisms: “The essence of therapy is experienced within the transference, and for Sonia and myself this involved her dependence on me and her pervasive fear of the separation that was essential for effective therapy and change… Therapy enabled us to feel close, for Sonia almost to feel part of me as she did her daughter, and having come close, to have the chance to separate in a different and more individual way” (p. 63). Hingley describes her approach as mingling self-psychology with the “transference themes, unconscious conflict and related defences of more classical analytic theory” (p. 63). Although the role of qualitative versus quantitative studies is often debated, particularly under the rubric of evidence-based practice, Hingley’s example emphasizes the point made by Mishna, Van Wert, and Asakura (2013) that the client-therapist relationship is both essential and difficult to quantify or measure, due in large part to the fact that psychodynamic therapy demands that each client be understood as an individual, making it especially hard to generalize its effects. Gallop and O’Brien (2003) contend that psychodynamic theory is essential in psychiatric nursing due to the profession’s emphasis on “understandings of therapeutic use of self, principles of empathy, respect, and attention to the subjective experience of the other” (p. 213), which they see as incomplete without a thorough understanding of psychodynamic theory. Rather more persuasively, Hemsley (2010) argues that psychodynamic treatment of PTSD can be helpful in part because “psychodynamic approaches view reactions to trauma as highly idiosyncratic (Levy & Lemma, 2004) where no uniform response should be expected and the impact of the trauma can be explored by achieving an understanding of the particular meaning that the events have brought into the patient’s life (Garland, 1998)” (p. 15). In her case study, Hemsley (2010) describes how the therapeutic relationship, in particular the deployment of transference, helped a 22-year-old woman who had developed PTSD after witnessing the burglary of her apartment and the assault of her boyfriend but also, in Hemsley’s view, because she was abandoned as a child by her father, something which the use of psychodynamic therapy allowed the practitioner to explore, whereas cognitive behavioral therapy, often used with sufferers of PTSD, would likely not have addressed the significance of the client’s childhood trauma.

Unlike more prescriptive approaches, contemporary psychodynamic theory and its associated therapies are multiple and amorphous. It would be difficult, even impossible, to find a clinician content to practice strictly in the Freudian model, or to enact the scenario I described in my opening tableau – unless, perhaps, one is a character in a Woody Allen film. However, I find it equally difficult to conceive of a therapeutic endeavor in which the therapist-client relationship is not central to the success or failure of the work, or in which the client’s past experiences, emotions, and thoughts are not regarded as supremely important. To that extent, I do and will continue to use a psychodynamic approach in my practice – as do, I would argue, all practitioners, including those who claim to be violently opposed to psychodynamic theory. Surely much of Freud’s original work is outdated, even offensive to women and members of minority populations; until recently, I would have included the idea of transference under that umbrella. However, through my research and the wisdom of far more experienced practitioners, I am now at least open to the possibility that transference could be a useful, if not essential, tool in my therapeutic toolkit.

References

Bliss, S. & Rasmussen, B. Reflections on contemporary psychodynamic theory in clinical social

work. Journal of Social Work Practice, 27 (3), 211-215.

Gallop, R. & O’Brien, L. Re-establishing psychodynamic theory as foundational knowledge for

psychiatric/mental health nursing. Issues in Mental Health Nursing, 24(2), 213-228.

Hemsley, C. (2010). Why this trauma and why now? The contribution that psychodynamic

theory can make to the understanding of post-traumatic stress disorder. Counselling Psychology Review, 25 (2), 13-20.

Hingley, S. (2001). Psychodynamic theory and narcissistically related personality problems:

Support from case study research. British Journal of Medical Psychology, 74(1), 57-73.

Hutchison, E. (2013). Essentials of human behavior: Integrating person, environment, and the

life course. Los Angeles, CA: Sage.