Paul CammellConsultant Psychiatrist, Flinders Medical Centre

Lecturer, Flinders University

1. Discussion of cultural context: Australian 1. Discussion of cultural context: Australian psychotherapeutic culture (psychiatric and other)psychotherapeutic culture (psychiatric and other)

2. Discussion of psychodynamic theories – relevance to 2. Discussion of psychodynamic theories – relevance to your training and practice in generalyour training and practice in general

* * Toolbox of concepts Toolbox of concepts **Recommended ReadingsRecommended Readings

3. Three Lectures: Prof Kalucy, Dr Paul Cammell and Dr 3. Three Lectures: Prof Kalucy, Dr Paul Cammell and Dr Robin ChesterRobin Chester

Psychodynamically informed practice

Psychoanalytic Psychotherapy: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 psychiatrists:Ranges of modalities adopted by psychiatrists:Formal psychoanalysis, psychoanalytic psychotherapy, psychodynamic psychotherapy, insight-oriented psychotherapy, psychodynamically-informed psychiatric management

Conflicts with the era of managed care, health insurance funds, evidence based medicine, health management, time-limited, cost efficient approaches

Role of Psychotherapy Outcomes Research

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

Classical Freudian Technique

• Transference Interpretation

• Dreams, Parapraxes

• Conflict and Defence

• Remembering, repeating, working through… Nachtraglichkeit

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., 33:433-438.

• Strachey, J. (1969). The Nature of the Therapeutic Action of Psychoanalysis. Int. J. Psycho-Anal., 50:275-292

• Winnicott, D.W. (1956). On Transference. Int. J. Psycho-Anal., 37:386-388

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

Ego Psychology, Neofreudian approaches

• Ego defenses

• Countertransference• Heimann

, P. (1950). On Counter-Transference. Int. J. Psycho-Anal., 31:81-84

• 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., 3:43-47

ERIKSON’S EIGHT STAGES OF THE LIFE CYCLEERIKSON’S EIGHT STAGES OF THE LIFE CYCLE

Trust versus MistrustTrust versus Mistrust (Birth to Approximately 18 Months) (Birth to Approximately 18 Months)

Autonomy versus Shame and DoubtAutonomy versus Shame and Doubt (Approximately 18 Months (Approximately 18 Months to Approximately 3 Years)to Approximately 3 Years)

Initiative versus GuiltInitiative versus Guilt (Approximately 3 Years to Approximately 5 (Approximately 3 Years to Approximately 5 Years)Years)

Industry versus InferiorityIndustry versus Inferiority (Approximately 5 Years to (Approximately 5 Years to Approximately 13 Years)Approximately 13 Years)

Identity versus Role ConfusionIdentity versus Role Confusion (Approximately 13 Years to (Approximately 13 Years to Approximately 21 Years)Approximately 21 Years)

Intimacy versus IsolationIntimacy versus Isolation (Approximately 21 Years to (Approximately 21 Years to Approximately 40 Years)Approximately 40 Years)

Generativity versus StagnationGenerativity versus Stagnation (Approximately 40 Years to (Approximately 40 Years to Approximately 60 Years)Approximately 60 Years)

Integrity versus DespairIntegrity versus Despair (Approximately 60 Years to Death) (Approximately 60 Years to Death)

Narcissistic-Psychotic DefensesNarcissistic-Psychotic DefensesProjectionProjectionDenialDenialDistortionDistortionSplittingSplitting

Immature DefensesImmature DefensesActing outActing outBlockingBlockingHypochondriasisHypochondriasisIntrojectionIntrojectionPassive-aggressive behaviorPassive-aggressive behaviorProjectionProjectionRegressionRegressionSchizoid fantasySchizoid fantasySomatizationSomatization

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 mother–child relationship: Methodological considerations. Psychoanal Stud Child. 1961;16:25.

Defense Mechanisms

Neurotic DefensesNeurotic DefensesControllingControllingDisplacementDisplacementDissociationDissociationExternalizationExternalizationInhibitionInhibitionIntellectualizationIntellectualizationIsolationIsolationRationalizationRationalizationReaction formationReaction formationRepressionRepressionSexualizationSexualization

Mature DefensesMature DefensesAltruismAltruismAnticipationAnticipationAsceticismAsceticismHumorHumorSublimationSublimationSuppressionSuppression

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 mother–child relationship: Methodological considerations. Psychoanal Stud Child. 1961;16:25.

Defense mechanisms

Attachment Theory

Bowlby: Attachment and Loss Trilogy

Evolutionary science, Ethology

Grief, Privation, Deprivation

(Maternal) attachment figure and security

Internal Working Models

Attachment (Proximity seeking)

Separation (Anxiety, Anger)

Loss (Sadness, Depression)

Questions ?Questions ?

Recommended ReadingsRecommended Readings

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

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

Lacan

• The French and Latin-American psychotherapy cultures

• Theory, Philosophy and Psychotherapy

• The Three Orders, Linguistics, Structuralism

Borderline Personality Disorder

“The Problem Patient of Our Time”

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

Borderline Syndromes – History1. Psychoanalysis

– 1930s-1950s Stern, Knight– 1960s-1970s Kernberg, (Winnicott, Khan, Bergeret)

2. 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”

3. Modern “evidence-based” psychotherapy– 1970s-1990s Object Relations BasedTransference 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)

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)

– Otherstructured, crisis plans, patient responsive, limit setting,

team-based

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

Giovanni Liotti and Attachment Disorders

• Ethology/evolutionary research: motivational systems (and IWM’s)– eg care-seeking, care-giving, sexual—pair bonding, ranking—

dominance/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

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

Borderline Personality and “abuse” or “trauma”

Judith Herman:

Complex PTSD “sexual abuse”

ERS Nijenhuis, Onno van der Hart:

Psychotraumatology and

Dissociative Disorder

Questions ?Questions ?

Case for Next WeekCase for Next Week

Recommended ReadingsRecommended Readings

Recommended Readings:Recommended Readings:General texts, including evidence based reviews:General texts, including evidence based reviews:New Oxford Textbook of Psychotherapy New Oxford Textbook of Psychotherapy (Gabbard, Beck, (Gabbard, Beck, Holmes)Holmes)What works for whomWhat works for whom, Roth & Fonagy, Roth & FonagyStandards and Guidelines for the PsychotherapiesStandards and Guidelines for the Psychotherapies (Paul (Paul Cameron, Jon Ennis & John Deadman Eds) eg Chapter 3Cameron, Jon Ennis & John Deadman Eds) eg Chapter 3

Basic Approaches to Psychodynamic PsychotherapyBasic Approaches to Psychodynamic Psychotherapy:: David Malan (David Malan (Individual Psychotherapy and the Science of Individual Psychotherapy and the Science of PsychodynamicsPsychodynamics), Glen Gabbard (), Glen Gabbard (Psychodynamic Psychodynamic PsychiatryPsychiatry), Nancy McWilliams (), Nancy McWilliams (Psychoanalytic Psychoanalytic Psychotherapy: A Practitioner’s Guide), Psychodynamic Psychotherapy: A Practitioner’s Guide), Psychodynamic Diagnostic and Statistical ManualDiagnostic and Statistical Manual

Models and Theories:Models and Theories: Comprehensive Textbook of PsychiatryComprehensive Textbook of Psychiatry (Kaplan & (Kaplan & Sadock), Chapters 6 and 30Sadock), Chapters 6 and 30