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Psychoanalytic Psychotherapy

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This book is an introductory textbook for psychiatrists and psychologists who use psychotherapy in a psychoanalytic attitude in their daily professional work with patients. It was developed from the experiences of German psychoanalysts teaching in China between 1997 and 2010. The idea of a basic textbook was developed in order to facilitate the teaching and learning process.The basic idea of this book is to give the reader an introductory understanding of the psychoanalytic theory of the human mind, the psychic development, psychic conflicts, trauma, symptom formation, and dreams. Related to these theoretical aspects the book then introduces the fundamentals of psychoanalytic-oriented psychotherapy. The first part of this book deals with important technical aspects of the psychotherapeutic treatment such as the therapeutic relationship, the setting, the diagnosis, and the process of treatment. The second part explores the psychoanalytic understanding of specific clinical disorders, including neuroses and personality.Psychoanalytic Psychotherapy: A Handbook seeks to provide a complete overview from a psychoanalytical point of view of theoretical and clinical aspects of psychodynamic or psychoanalytic psychotherapy.

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Chapter One - Psychoanalytic Theory of the Human Mind

ePub

Hermann Schultz, Joachim Rothhaupt, and Michael Wolf

Psychoanalytic models of the mind

Hermann Schultz

What is psychodynamic psychotherapy; what does the term “psychodynamic” mean? For an answer to this question, let us look at the origins of psychodynamic science, rooted in psychoanalysis and developed by Freud from 1893 onwards. Psychiatric diagnosis in Freud's time was no more than classifying people into different diagnostic categories, for instance, the so-called “psychopathic personalities” with hysteric, perverse, criminal, or addictive traits, the psychoses (schizophrenia, manic–depressive illness), neurasthenia, etc. Today, our diagnostic systems in psychiatry are much more refined, operationalised, and validated than they were at the turn of the twentieth century: we have ICD-10 or DSM-IV guide us. Nevertheless, the content of these diagnostic systems, too, is restricted to descriptive symptom diagnoses and does not tell us anything about the psychodynamics of the patient's psychic disease. Therefore, for our psychotherapeutic purposes, the symptom diagnosis has to be supplemented by a psychodynamic diagnosis (see “Operationalised psychodynamic diagnosis” in Chapter Seven).

 

Chapter Two - Psychoanalytic Theory of Psychic Development through the Life Span

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Hanni Scheid-Gerlach, Klaus Kocher, Christine Gerstenfeld, and Wolfgang Merkle

Methodology of psychological theory of development

Hanni Scheid-Gerlach

The psychoanalytic theory of human development is founded on different scientific methods: reconstruction, observation, and baby-watching.

Reconstruction

The contribution of psychoanalysis to human understanding is its explanation of neurotic mental disorders in terms of fixation or regression of the libido. Libido, a term that means desire, is defined as the instinctual sexual energy underlying all mental activity. The development of human beings goes through different stages, which Freud called the oral, anal, and genital (oedipal) phases. Since the development of this theory, conflicts in adults can usually be reconstructed through their experience in childhood and how they developed from birth until puberty. To understand mental disorders, it is necessary to reconstruct the childhood of patients, during which they developed special defences that are responsible for their present suffering.

 

Chapter Three - Conflict, Trauma, Defence Mechanisms, and Symptom Formation

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Michael Wolf, Alf Gerlach, and Wolfgang Merkle

Primary and secondary process

Michael Wolf

T he main topic of psychoanalysis is reality, and not, as is often asserted, the irrational. This concept of reality (defined by the reality principle posited by Freud) addresses the cognitive perception of reality (rather than delusion, thinking disorders, and other distortions investigated through psychiatric exploration). Furthermore, it addresses social perception and the recognition of reality. This is the main meaning of the “Oedipus complex”, referring to the fundamental acceptance of the differences between the sexes and the generations and the position of the person in this biological as well as social order.

The pleasure principle (defined by Freud as the universal tendency to avoid reluctance and to provide pleasure by discharging of tension) relates exclusively to the tensions and the satisfactions of drives. The reality principle is a modification of the pleasure principle that takes into account that it is sometimes necessary for the satisfaction of drives and, therefore, the achievement of pleasure to be deferred because of the prevailing conditions.

 

Chapter Four - Dreams

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Joachim Rothhaupt and Stephan Hau

The history of the theory of dreaming and dream research

Joachim Rothhaupt

P sychoanalytical dream research is concerned with three main aspects of dreaming:

 

Freud's dream theory

The theory introduced by Sigmund Freud at the beginning of the twentieth century can be seen as a turning point in the scientific investigation of dreams. The psychoanalytic dream theory has deeply influenced most of the current clinical theories on dreaming and, to some extent, modern experimental investigation of dream states as well. In the 1950s, the discovery of REM sleep and of the profile of typical different sleeping states during the night provided the starting point for modern sleep and dream research. This laboratory research has revealed overwhelming new knowledge about the dreaming mind and about the features of the dream state. I will come back to this type of research and to some of the most important findings later. Freud's “main idea was that dreams serve a function of wish fulfilment. He distinguished between a manifest level of dream content (the dream as it is remembered and reported) and a latent level of dream content that can be inferred by following the associations of the dreamer to the single parts of the dream and by tracing back the different steps of dream work in which the material (infantile material, day residues, etc.) is condensed, displaced, or secondarily revised. The underlying assumption is that the associative chains of the dreamer to every part of the dream will lead to the mental processes that gave rise to the dream and thereby reveal the unconscious (latent) meaning of the dream”. (Hau, 2004, p. 1)

 

Chapter Five - The Therapeutic Relationship

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Ulrich Ertel, Klaus Kocher, and Hanni Scheid-Gerlach

Expectations and aims of the treatment

Ulrich Ertel

Strictly speaking, the aim of psychoanalysis is to achieve a structural personality change through psychoanalytic treatment. This means a reorganisation of the personality that is profound and lasting and enables the person concerned to best deal with the prospects, challenges, and burdens of his life within the scope of his capabilities and limitations. This far-reaching claim is often made in contrast to therapeutic goals, focusing on the elimination or alleviation of symptoms and on behaviour change. Meanwhile, there is a tendency to acknowledge a floating crossover between goals and aims in psychoanalysis and psychotherapy depending on the length (short- vs. long-term) and intensity (frequency) of treatment.

Freud tried to define the aims of psychoanalysis both topographically and structurally. It stretches from his famous principle of making the unconscious conscious, or “Where id was, there ego should be” (1933a, p. 81) to his advice that the analysis should provide the most beneficial conditions for the ego functions. In his Studies on Hysteria (1895d), he wrote, “a lot is gained if we succeed in turning the hysterical misery into common calamity; against the latter one will defend himself better with a recovered psychic life” (p. 307). In several places, he mentions the ability to work, love, and enjoy. Many analysts agree that to reach a balance between parts of the id, the ego, and the superego is one aim of psychoanalysis.

 

Chapter Six - The Setting in Psychoanalytic Psychotherapy

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Christine Gerstenfeld and Hanni Scheid-Gerlach

Frame and setting of the psychotherapy

Christine Gerstenfeld

What distinguishes the psychotherapeutic dialogue from the patient's talk about the same problems with a friend, a relative, a religious mentor, or a doctor of another speciality? What makes clear to the patient that in the psychotherapist's office he or she receives psychotherapy, and additionally, a psychoanalytically orientated type? It is the frame of the treatment that carries the fundamental function to initiate, to maintain, and to protect the essence of the psychotherapeutic process and which, at the same time, becomes a most valuable tool for the understanding of the unconscious psychic conflicts of the patient.

Components of the frame or setting of psychoanalytic therapy

In order to understand what is encompassed by the concept of “frame” or “setting”, consider the list set out in Table 6.1, which contains factors that have been considered in the literature to belong to the frame or setting of psychoanalysis or psychoanalytic psychotherapy.

 

Chapter Seven - Diagnosis and Treatment in Psychoanalytic Psychotherapy

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Matthias Elzer, Wolfgang Merkle, Hermann Schultz, and Alf Gerlach

The initial interview

Matthias Elzer

In general, psychotherapy is a conscious and intentional process of interaction that can be described as follows.

Before we start any kind of psychotherapeutic treatment, a diagnostic phase to assess the patient's complaints and illness is necessary. The initial interview is a very important and interesting first step towards understanding the patient and clarifying the indication for treatment.

In his paper “On beginning the treatment” (1913c), Freud compared psychoanalytical treatment with the game of chess, where we can learn only the beginning and the end of the game by reading books. This means that we can learn how to begin a therapy by systematically using techniques. Nevertheless, Freud did not describe any technique for an initial interview; he used the first weeks as a test run for therapy.

Influenced by psychiatry, some concepts of a structured interview were developed, for example by Gill, Newman, and Redlich (1954) and Kernberg (1981). Psychoanalysis offered different forms of therapy (psychoanalysis, psychodynamic, or psychoanalytic psychotherapy, short-term therapy, group therapy) not only for patients with neuroses, but also for patients with severe personality disorders, and psychosomatic and psychotic disorders. The questions of indication and contraindication were raised when considering the most suitable form of psychoanalysis for each case.

 

Chapter Eight - Psychopathology and Psychodynamics of Neurosis

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Matthias Elzer, Michael Wolf, Hermann Schultz, Irmgard Dettbarn, and Anne-Marie Schloesser

General theories of neuroses

Matthias Elzer

Historical aspects of the term “neurosis”

The term “neurosis” was first used by the Scottish physician, Cullen, in 1787; he wanted to express his understanding that mental disorders are caused by the nervous system. He collected typical neuroses and psychosomatic and neurological disorders together under this term.

Freud used different terms for, and concepts of, neuroses, which changed during later decades. Table 8.1 provides an overview of the terms used in Freud's literature.

Freud tried to avoid differentiating between neuroses and psychoses and he separated neurosis from perversion.

The actual understanding and use of the term neuroses is described later.

Trauma vs. conflict

In the beginning of psychoanalysis, Freud and others, such as Breuer, assumed from their clinical experiences that the origin of suffering from neuroses is a sexual seduction or abuse in the patient's childhood. The reason for a neurosis is a traumatic experience. We call this the trauma theory. This was the beginning of a “trauma model of mental disorders”.

 

Chapter Nine - Psychopathology and Psychodynamics of Psychosomatic Disorders

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Matthias Elzer, Wolfgang Merkle, and Michael Wolf

General aspects of psychosomatic medicine

Matthias Elzer

The history of psychosomatic medicine in Western countries

The roots of the psychosomatic approach go back to Ancient Greece, more than 2,300 years ago. On the one hand, there was the famous physician Hippocrates (460–377 BC), whose understanding was based on the “humoral model” of the body and its diseases.

Today, many medical terms reflect this understanding (e.g., melancholia (Greek: black bile)). This model is similar to traditional Chinese medicine. But Hippocrates’ understanding was mostly somatically orientated.

On the other hand, there were some philosophers, such as Aristotle and Plato (427–347 BC), who were interested in questions about human beings and about the science of nature, too. Plato wrote that the human body should not be treated without the psyche and the body has to be treated by “nice words”. The word “psychotherapy” could have been used first by Plato.

During the Middle Ages, the understanding of the human body and its diseases were influenced by a pre-scientific magic thinking regarding bad influence. The therapy was a kind of cleaning and detoxification (catharsis). Mental disorders were seen as the results of sins and as signs of guilt. Better understanding of the physical and biological processes of nature led to a focus on the aspects of natural sciences. The French philosopher and scientist Descartes (1595–1650) postulated a splitting into matter (res externa) and cognition (res cogitans). Since that time, medicine was divided in two parts, which we term the dualism of body and psyche. Developing medical science was much more interested in somatic and natural scientific understanding of the human being and its diseases and neglected the social and psychic dimension of illness, which was finally brought into focus at the end of the nineteenth century. However, some physicians pointed out the influence of psyche somewhat earlier, such as Heinroth in 1818, in Germany, who used the word “psychosomatic” first.

 

Chapter Ten - Psychotic Disorders, Addiction, and Suicide

ePub

Ulrich Ertel, Michael Wolf, Matthias Elzer, and Hanni Scheid-Gerlach

Psychodynamics and psychotherapy of psychosis

Ulrich Ertel

Conflict and/or dilemma

In recent years, there has been an increasing tendency to use bio-psychosocial models in psychiatry. So, for many, it is business as usual to reflect on the patient's most relevant conflicts in the context of considerations on pathogenesis, diagnosis, and therapy. However, mostly, the crux of the matter is the real conflict constellations within the psychosocial field being an additional burden, or forming and complicating the process and outcome of the psychotic disease. Thus, one is dealing with conflicts as an effect or consequence of the illness.

Yet, one hardly deals with intrapsychical conflicts which might have co-determined or even caused the psychotic disease. So, in the therapeutic work and in supervisory activities, it is useful to ask what conflict (or dilemma), what quandary, should be alleviated through some sort of compromise, resolved, handled, or ignored through denial and garbling (Mentzos, 2001a, b). This and the additional question (what is the use and function for the persistent symptom with regard to the presumed intrapsychical contradiction and the resulting intrapsychical tension?) lead us to a better understanding of aberrant patterns in experience and behaviour.

 

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