Introduction

An introduction to psychodynamic psychotherapy was given in the "Psychological Therapies" section. This section will cover psychodynamic psychotherapy in some more depth.

Basic Psychodynamic Concepts

Psychodynamic and psychoanalytic psychotherapies make use of a number of concepts regarding the characteristic workings of the mind under conditions of normality, neurosis, personality disorder and psychosomatic conditions.

Change and Development

Any human being at any time is in the process of change and development. This is most obvious in children and adolescents but is no less true of adults in middle and late life. As such their needs and expectations are changing both in material and relationship terms. Moreover within the range of life events, such as bereavement, the human reaction to these follows a more-or-less predictable course, unless interrupted by psychopathology.

Key Relationships and Transference

During the course of development, children establish complex relationships with key people, particularly parents, which include attachment and the meeting of a variety of needs which change over time. When such needs are not met or where the relationship is broken, the potential is there for the repetition, avoidance or idealisation of equivalent subsequent relationships through the phenomenon of transference.

The term transference refers to the unconscious influence of past learning of traumatic interpersonal relationships on present emotional responses, behaviour and relationships. This maladaptive learning stems from childhood experiences and interferes with normal relationship and decision-making.

"What are transferences? They are new editions or facsimiles of the impulses and fantasies which are aroused during the process of analysis; but they have this peculiarity, which is characteristic of their species, that they replace some earlier person by the person of the physician. To put it another way: a whole series of psychological experiences are revived, not as belonging to the past, but as applying to the person of the physician at the present moment."

One of the objectives of psychotherapy is to enable the patient to recognise these previously unconscious distortions of interpersonal perception and to respond more appropriately to people in the future.

The ordinary, straightforward doctor-patient relationship is not of itself a transference relationship. It can, however, by its nature foster such relationships particularly where dependency is a predominant theme.

• a positive transference is one where the predominant emotion is in favour of the doctor.
• a negative transference is one where the predominant emotion is hostility to the doctor (assuming that in reality (s)he does not deserve it!).
• counter-transference is the doctor's transference feelings towards the patient and as such may be positive or negative.

An understanding of transference is therefore necessary not only to understand "academically" the neuroses and personality disorders but also the day-to-day vagaries of doctor-patient interaction.

Conflict and Anxiety

Anxiety arises through conflict between one or more "disturbing concerns" and one or more "reactive concerns".

• Brief transient conflict produces acute anxiety until the conflict passes, is resolved or is modified by mental defences.
• Chronic conflict brings about the longstanding deployment of defences which becomes part of a personality trait, e.g. obsessionality.

A Sense of Self

During the course of normal development, a person develops a sense of themselves as individuals capable of independent perception, thought and initiation of action. There is a sense of an integrated personality with congruent ideals and values linked to a sense of self-esteem. During the course of abnormal development the sense of self may be less soundly formed and become evident in clinical states, e.g. poor self-esteem in depressive states.

Unconscious Mental Mechanisms

Every human being is actively engaged in mental activity, much of it unconscious, directed to maintaining an emotional equilibrium in the face of impulses from within (e.g. aggression and sexuality) and emotional demands from others. Evidence for such unconscious activity is to be seen in the case of dreams and slips of the tongue which reveal more than is consciously intended.

In order to maintain this emotional homeostasis we employ, almost entirely unconsciously, a number of mental mechanisms - accordingly they are more obvious to our observant friends than to ourselves. Used in moderation these are essential to mental health. Overused they can become pathological because they impart a rigidity of thinking and relating which makes living more-or-less difficult. Certain other mental mechanisms (marked in the section on Defence Mechanisms) are more often implicated in psychopathology and often indicate greater anxiety which is being held back by more desperate and primitive defences.

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