Treatment Methods (Fach) / L3 (Lektion)

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• History of psychodynamic psychotherapy Foundations in psychoanalysis (Freud) and psychoanalytical psychotherapy Illness of the mind exist because of the unconscious (like repressed memories or desires) Defenses limit the ability of working on ones own problems and keep the pathology in place Focus: Exploring and understanding the unconscious and all of its facets.
• ID unconscious level only instinct to survive instinct to destroy
• EGO develops ininfancy  keeps check on id 
• Superego where morality resides  encourages social responsibility
• Psychoanalysis: interventions ◦(Free) association ◦Exploring the past (relationships) and the transference between the patient and therapist ◦Clarification, Confrontation and Interpretation ◦Exploration of countertransference (feelings elicited in the therapist during the treatment) ◦Neutrality: in order not to bestow ones own unconscious perception on the therapy.
• Main defenses in psychoanalysis Repression (“I won’t think about it!”) • Denial (“it never happened!”) • Projection (“it is all your fault!”) • Displacement (ventilating frustration towards your colleague instead of your boss) • Regression (responding by behaving childlike and in need of help most of the time) • Sublimation (becoming a psychologist in order to help others, to make up for missed help and understanding earlier in life)
• Psychodynamic psychotherapy All treatments based on the rich foundations of psychanalysis and psychoanalytical psychotherapy. Difference: oEvidence based (with RCT’s). oMore focus on the here and now (but keeps in mind what the effects of the past are). oNot always as neutral as in psychoanalysis (depending on the treatment method).
• Modern psychodynamic psychotherapy methods ◦MBT: Mentalis(z)ation based therapy/treatment ◦TFP: Transference focused therapy ◦ISTDP: Intensive short-term dynamic psychotherapy (not discussed)
• Mentalization based treatment Mentalization Developed for borderline personality disorder. Attachment theory important background Focus on enhancing mentalizing ability and improving self regulation. The ability to understand other peoples feelings, motivations and needs. ◦Gets worse for everyone when anxiety levels rise, so managing the window of tolerance is important!
• Window of tolerance Emotion regulation problems and hypersensitivity threaten mentelization.
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• 4 modes of (non)mentalization 1. Mentalizing mode: Feelings, thoughts, identity are integrated and you can reflect on yourself and others. 2. equivalent mode: How we see ourselves is what we expect to find in the outside world. (activating coping; fact is a fact, even when it is a feeling or an opinion). 3. Pretend mode: Overcompensation of grandiosity, but also denial of reality. (deactivating coping; eg. ignoring anxiety) 4. Teleological mode: The belief that only what one can feel or actually see is real. Example: cutting oneself means I feel because it hurts. (activating coping; goal and outcome oriented)
• MBT interventions • Empathetic responses help regulate affect in the patient • Explore and clarify experiences. • Challenge or confront experiences (when the patient is able to mentalize!) • Mirroring affect/emotions to help the patient understand themselves (and regulate themselves) • Discuss the relationship when reenactments or transference occurs (mentalizing the relationship)
• MBT: and what about the therapist? • Not-knowing • Patience. Able to withstand some emotional storms • Accepting and legitimizing (multiple points of view possible) • Helps to clarify a lot • Points out of things don’t compute with eachother
• Kernberg on Normal and abnormal personality organisation Personality organization differs from personality disorder, but are related.◦Neurotic◦Borderline◦Psychotic Three aspects are affected:•The indentity•Reality check•Defenses
• Neurotic personality Integrated identity◦Knows his strengths and weaknesses◦Differentiated concept of good and bad of the self Reality check◦Non-psychotic◦No great distortion in thinking Defense◦Developed defense mechanisms◦Sublimation, humor, rationalization
• Borderline personality Polarized identity◦Concepts of good and bad about the self◦Non integrated aspects (I am good or bad as a whole, can’t be both at the same time). Reality check◦Sometimes mini psychosis◦No great distortion in thinking except black-white thinking. Defense◦Primitive defense mechanisms◦Projections, denial, displacement
• Psychotic personality Diffuse identity◦Badly integrated identity.◦Different personalities. Reality check◦Distorted. Hallucinations and others. Defense◦Primitive defense mechanisms◦Projections, denial
• TFP: interventions Focus on the integration of the self (also in relation to others) •Working with a contract for clear conditions in the therapy (what is allowed and what is not) ◦This is to help the patient regulate emotions (quite differently from MBT) •Clarifying and interpreting transference (linking the here and now with the past) •Feelings in the countertransference is “returned” to the patient (as the rightful owner of these feelings), but not confrontational. The therapist wil try and help the patient feel what he felt using clarification and interpretation. •Confronting when avoidance is detected (as a defense) and therefore not just waiting for free associations to happen (which don’t always occur because of the defenses) •Technical neutrality, but less rigid than in psychoanalysis.
• TFP: what about the therapist? • Neutral and calm: Even, and above all, when (couter)transference occurs! • Present and responsive when there is an actual crisis. • Patience, even more so when compared to MBT. • Always aware of what reenactment is taking place and only clarify if sufficiently certain. •Monitoring the explicit and implicit signals in communication •Less focus on emotion regulation than MBT.
• Differences between MBT and TFP MBT:The therapist is actively envolved in emotion regulation and focusses on protecting the relationship.The therapist works with, but doesn’t interpret reenactments. The therapist has a not knowing stance, stimulating the patient to reflect or mentalize about himself and the situation.Focus on individual and groupsessions (more mentalizers, more perspectives)Generally more fit for low-level borderline (because of the regulatory nature) TFP:The therapist is an important object relation through which reenactments can occur. The therapist aims to discuss the occurring reenactments. The therapist interprets the object-relational reenactment. Individual psychotherapy.Less fit for low-level borderline (because it is more confrontational by nature)
• Transference differences of BPD and NDP BPDRapidly developingIntenseUnstable, confusingTypically Ego dystonicPressure to “Do something”Typically come from patient’stransference projectionsTypically reflectcomplementary identificationsCentral channel ofcommunication NPD• Often slowly developing• Subtle• Familiar range of affect• May be ego syntonic• Easy to miss or rationalize• Variable combination of patientand therapist factors• May reflect concordant orcomplementary identifications• Less central channel
• Aproach with narcicism NPD Stay aware of counter-transference (getting annoyed, angry, bored).Don’t be to eager or fast. It takes timeValidate, understand, be flexible and move with your client instead of against. Build an alliance. Don’t confront all the time. Consider the emotional pain and the tendency to overcompensate (attack you or leave). Test interventions. Small enough not to damage the alliance beyond repair. Beware of idealization.

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