Relational Psychotherapy -recent advances in psychodynamic psychotherapy and applications

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Psychoanalytic Psychotherapy Recent Trends
Application

• Dr Douglas Kong
• Retired Consultant Psychiatrist
• dsgkong_at_gmail.com

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Topics to be covered today

• What works in psychotherapy
• Trend towards relational brief account of
  Object Relations
• Group applications of Bions theory

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Caregiver/Therapist
Child/Client
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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

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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

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Safe Space (Kotani)
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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

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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

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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

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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

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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

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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)

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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

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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

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Implications for current clinical practice

• Relational emphasis
• Intersubjective
• Use more than one roadmap
• For non-therapist, pay attention to the person

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Dr Douglas Kong dsgkong_at_gmail.com