Introduction to

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Introduction to Psychodynamic Psychiatry
Psychotherapy
RMO Training Programme, 2012
Paul Cammell Consultant Psychiatrist,
Flinders Medical Centre Lecturer, Flinders
University
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1. Discussion of cultural context
Australian psychotherapeutic culture (psychiatric
and other)2. Discussion of psychodynamic
theories relevance to your training and
practice in general Toolbox of concepts
Recommended Readings3. Three Lectures
Prof Kalucy, Dr Paul Cammell and Dr Robin
Chester
Psychodynamically informed practice
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Psychoanalytic Psychotherapy -processes
transference, interpretation, resistance,
enactment, etc -analytic triangles Malan--of
person/conflict -models classical, object
relations, self psychology, ego psychology,
relational, interpersonal, intersubjective,
attachment orientation, mentalization, Lacanian,
etc -training (theoretical, clinical
supervision, training analysis, infant
observation)Ranges of modalities adopted by
psychiatristsFormal psychoanalysis,
psychoanalytic psychotherapy, psychodynamic
psychotherapy, insight-oriented psychotherapy,
psychodynamically-informed psychiatric
managementConflicts with the era of managed
care, health insurance funds, evidence based
medicine, health management, time-limited, cost
efficient approachesRole of Psychotherapy
Outcomes Research
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Universal Techniques

• Focus on affect and expression of emotion
• Exploration of attempts to avoid distressing
  thoughts and feelings
• Identification of recurring themes and patterns
• Developmental focus exploration of past
  experiences
• Focus on interpersonal relations
• Focus on the therapeutic relationship
• Exploration of wishes and fantasies

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Classical Freudian Technique

• Transference Interpretation
• Dreams, Parapraxes
• Conflict and Defence
• Remembering, repeating, working through
  Nachtraglichkeit

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Transference

• Freud, S. (1912). The Dynamics of Transference.
  The Standard Edition of the Complete
  Psychological Works of Sigmund Freud, Volume XII
  (1911-1913) The Case of Schreber, Papers on
  Technique and Other Works, 97-108.
• Freud, S. (1914). Remembering, Repeating and
  Working-Through (Further Recommendations on the
  Technique of Psycho-Analysis II). The Standard
  Edition of the Complete Psychological Works of
  Sigmund Freud, Volume XII (1911-1913) The Case
  of Schreber, Papers on Technique and Other Works,
  145-156.
• Klein, M. (1952). The Origins of Transference.
  Int. J. Psycho-Anal., 33433-438.
• Strachey, J. (1969). The Nature of the
  Therapeutic Action of Psychoanalysis. Int. J.
  Psycho-Anal., 50275-292
• Winnicott, D.W. (1956). On Transference. Int. J.
  Psycho-Anal., 37386-388

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Object Relations and British Independent or
Middle Tradition

• Klein pre-Oedipal development, the
  paranoid-schizoid and depressive positions, envy,
  mourning
• Bion containment and alpha-beta function,
  psychotic personality
• Winnicott, holding, transitional phenomena, false
  self
• Balint, Fairbairn etc

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Ego Psychology, Neofreudian approaches

• Ego defenses
• Countertransference
• Heimann, P. (1950). On Counter-Transference. Int.
  J. Psycho-Anal., 3181-84
• Bion, W. R. (1967b), Notes on memory and desire,
  Psychoanalytic Forum, 2, 271-286
• Sandler, J. (1976). Countertransference and
  Role-Responsiveness. Int. R. Psycho-Anal.,
  343-47

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ERIKSONS EIGHT STAGES OF THE LIFE CYCLE
Trust versus Mistrust (Birth to Approximately
18 Months)Autonomy versus Shame and Doubt
(Approximately 18 Months to Approximately 3
Years)Initiative versus Guilt (Approximately 3
Years to Approximately 5 Years)Industry versus
Inferiority (Approximately 5 Years to
Approximately 13 Years)Identity versus Role
Confusion (Approximately 13 Years to
Approximately 21 Years)Intimacy versus
Isolation (Approximately 21 Years to
Approximately 40 Years)Generativity versus
Stagnation (Approximately 40 Years to
Approximately 60 Years)Integrity versus Despair
(Approximately 60 Years to Death)
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Narcissistic-Psychotic DefensesProjectionDenial
DistortionSplittingImmature DefensesActing
outBlockingHypochondriasisIntrojectionPassive-
aggressive behaviorProjectionRegressionSchizoid
fantasySomatization
Defense Mechanisms
Adapted from Vaillant GE. Adaptation to Life.
Boston Little Brown 1977 Semrad E. The
operation of ego defenses in object loss. In
Moriarity DM, ed. The Loss of Loved Ones.
Springfield, IL Charles C Thomas 1967 and
Bibring GL, Dwyer TF, Huntington DS, Valenstein
AA. A study of the psychological principles in
pregnancy and of the earliest motherchild
relationship Methodological considerations.
Psychoanal Stud Child. 19611625.
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Neurotic DefensesControllingDisplacementDissoc
iationExternalizationInhibitionIntellectualizat
ionIsolationRationalizationReaction
formationRepressionSexualizationMature
DefensesAltruismAnticipationAsceticismHumorSu
blimationSuppression
Defense mechanisms
Adapted from Vaillant GE. Adaptation to Life.
Boston Little Brown 1977 Semrad E. The
operation of ego defenses in object loss. In
Moriarity DM, ed. The Loss of Loved Ones.
Springfield, IL Charles C Thomas 1967 and
Bibring GL, Dwyer TF, Huntington DS, Valenstein
AA. A study of the psychological principles in
pregnancy and of the earliest motherchild
relationship Methodological considerations.
Psychoanal Stud Child. 19611625.
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Attachment TheoryBowlby Attachment and Loss
TrilogyEvolutionary science, EthologyGrief,
Privation, Deprivation(Maternal) attachment
figure and securityInternal Working
ModelsAttachment (Proximity seeking)Separation
(Anxiety, Anger)Loss (Sadness, Depression)
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Questions ?Recommended Readings
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Self Psychology

• Heinz Kohut
• Narcissism, Self pathology
• Self cohesion, shame, mirror/twin and other
  transferences

Kernberg

• Ego Psychology and Object Relations
• Borderline Personality
• Transference Focussed Psychotherapy and the
  Evidence-Based Paradigm

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Interpersonal, Relational Approaches

• Ogden, Sullivan, Mitchell, Aron, Stolorow,
  Orange, Bromberg
• The authority of the patient, co-construction and
  the analytic third
• Context, prejudice, the return of dissociation,
  focus on trauma, existential, humanistic and
  hermeneutic approaches

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Lacan

• The French and Latin-American psychotherapy
  cultures
• Theory, Philosophy and Psychotherapy
• The Three Orders, Linguistics, Structuralism

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Borderline Personality Disorder

• The Problem Patient of Our Time

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Borderline Personality and developmental
neuroscience

• Giovanni Liotti
• Disorganized Attachment and Borderline PD
• Peter Fonagy et al.
• Mentalization as a core construct
• Russell Meares
• Memory, frontal/pre-frontal function
• Glen Gabbard
• Mind-body interactions
• HPA axis, hippocampal volume, hemispheric
  lateralization
• Allan Schore
• Right Brain Development and affective regulation

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Borderline Syndromes History

• Psychoanalysis
• 1930s-1950s Stern, Knight
• 1960s-1970s Kernberg, (Winnicott, Khan, Bergeret)
• Psychiatry
• 1940s-1960s Ambulatory Schizophrenia (Zilboorg),
  Preschizophrenia (Rapaport), latent
  schizophrenia (Federn), pseudoneurotic
  schizophrenia (Hoch and polatin), schizotypal
  disorder (Rado)
• Late 1960s Borderline states (Knight),
  Borderline Syndrome (Grinker)
• Mid 1970s Borderline Personality (Gunderson et
  al.)
• 1980 DSM III Borderline Personality Disorder
• Modern evidence-based psychotherapy
• 1970s-1990s Object Relations Based?Transference
  Focussed Psychotherapy (Kernberg, Clarkin)
• 1990s Dialectical behaviour Therapy (Linehan)
  Mentalization-based treatment (Fonagy, Bateman,
  Target)
• 1990s-present Cognitive Analytic Therapy (Ryle),
  Conversational Model (Meares), Supportive
  Psychoanalytic Psychotherapy (Appelbaum),
  Schema-Focused Therapy and Systems Training for
  Emotional Predictability and Problem Solving (or
  STEPPS, Blum)

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Modern Therapeutic Approaches

• Pharmacotherapy
• HPA axis sensitization and anxiolytic medication
  (eg atypical antipsychotic medications)
• Serotonergic agents
• Psychotherapy
• Dialectical Behaviour Therapy (Linehan)
• Psychodynamic psychotherapy
• Mentalization-based (Fonagy, Bateman, Target et
  al.),
• Object-Relations based (Kernberg)
• Self-Psychology based (Meares)
• Other
• ?structured, crisis plans, patient responsive,
  limit setting, team-based

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Mentalization

• Theory of mind (Fonagy, Bateman, Target et al.),
  social biofeedback theory, mentalized
  affectivity
• Borderline Personality Disorder psychic
  equivalence and pretend modes splitting and
  dissociation disorganized trauma responses
  affect dysregulation

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Giovanni Liotti and Attachment Disorders

• Ethology/evolutionary research motivational
  systems (and IWMs)
• eg care-seeking, care-giving, sexualpair
  bonding, rankingdominance/submission,
  egalitarian/altruistic, intersubjective
• Attachment Disorganization and psychopathology
• borderline and antisocial PD, conduct disorder,
  emotional dysregulation and impulse control
  problems (HPA Hyperresponsiveness)
• Transgenerational transmission
• The Adult Attachment Interview

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Mentalization

• Theory of mind (Fonagy, Bateman, Target et al.),
  social biofeedback theory, mentalized
  affectivity
• Borderline Personality Disorder psychic
  equivalence and pretend modes splitting and
  dissociation disorganized trauma responses
  affect dysregulation

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Borderline Personality and abuse or trauma

• Judith Herman
• Complex PTSD? sexual abuse
• ERS Nijenhuis, Onno van der Hart
• Psychotraumatology and Dissociative Disorder

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Questions ?Case for Next WeekRecommended
Readings
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Recommended ReadingsGeneral texts,
including evidence based reviewsNew Oxford
Textbook of Psychotherapy (Gabbard, Beck,
Holmes)What works for whom, Roth
FonagyStandards and Guidelines for the
Psychotherapies (Paul Cameron, Jon Ennis John
Deadman Eds) eg Chapter 3Basic Approaches to
Psychodynamic Psychotherapy David Malan
(Individual Psychotherapy and the Science of
Psychodynamics), Glen Gabbard (Psychodynamic
Psychiatry), Nancy McWilliams (Psychoanalytic
Psychotherapy A Practitioners Guide),
Psychodynamic Diagnostic and Statistical
ManualModels and Theories Comprehensive
Textbook of Psychiatry (Kaplan Sadock),
Chapters 6 and 30