Introduction to Psychotherapy

An Outline of Psychodynamic Principles and Practice, Fourth Edition

Anthony Bateman, Dennis Brown, Jonathan Pedder

• Publisher: Routledge
• Year: 2010
• ISBN:
  9781136896453
• Edition: 4
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This fourth edition of Introduction to Psychotherapy builds on the success of the previous three editions and remains an essential purchase for trainee psychotherapists, psychiatrists and other professionals. It has been revised and extended to capture some of the current themes, controversies and issues relevant to psychotherapy as it is practised today.

Bateman has added new chapters on attachment theory and personality disorder and has developed further the research sections on selection and outcome. His new chapter on further therapies covers a variety of therapeutic movements and establishes links between these and classical psychoanalytical therapies.

Introduction to Psychotherapy is a classic text that has been successfully updated to provide a relevant and essential introduction for anyone interested in psychotherapy.

Part I
Psychodynamic principles

INTRODUCTION TO PSYCHODYNAMIC PRINCIPLES

It is widely agreed that about a third of all patients who go to their family doctor have primarily emotional problems. About half of these will have a recognizable psychiatric condition, with two-thirds of them having unmet needs. But only one in twenty is referred to a psychiatrist (Boardman, Henshaw, & Willmott, 2004). A still smaller proportion will be referred on for formal psychotherapy in the National Health Service (NHS). However, psychotherapy at varying levels will be appropriate for some patients at each of these stages. We will discuss these different levels and types of psychotherapy in further detail in Part II. The term ‘psychotherapy’ is used in both general and special ways; it includes forms of treatment for emotional and psychiatric disorders that rely on talking and the relationship with the therapist, by contrast to physical methods of treatment (such as drugs and electroconvulsive treatment).

Most psychotherapy in the general sense is carried out informally in ‘heart-to-heart’ conversations with friends and confidants. ‘Everyone who tries to encourage a despondent friend or to reassure a panicky child practices psychotherapy’ (Alexander, 1957, p. 148). Well-worn sayings such as ‘a trouble shared is a trouble halved’ make sense to everyone. Such help is more likely to be sought in the first instance from the most readily available help-giver, such as a friend, family doctor, priest, or social worker, rather than from a psychiatrist or psychotherapist. In the medical field, the art of sympathetic listening has always been the basis of good doctoring. There has been a risk that this might be overshadowed by the enormous advances in the physical sciences and their application to medicine, which have resulted in an increasing attention to diseased organs, to the relative neglect of the whole diseased person. In the last generation, interest has shifted back again to the individual as the focus of stress in the family and community, and psychodynamic principles have helped to illuminate this interest. While it is correct that many acute and major forms of psychiatric disturbance are best treated by physical methods, the addition of psychotherapeutic treatments may enhance outcomes both quantitatively and qualitatively. But the reverse is also true. Many less acute forms of neurotic and interpersonal problem are better helped by psychotherapeutic methods and in some disorders pharmacotherapy is relegated to a secondary level of intervention. For example, borderline personality disorder, a disorder characterized by marked interpersonal problems, can only be successfully treated using psychological treatment (Oldham, Phillips, Gabbard, et al., 2001; NICE, 2009). We shall take up this issue further in Part II, particularly in discussing levels of psychotherapy (p. 109) and selection (p. 238).

Historically there have been two major approaches to psychotherapy in the special sense, competing with varying mixtures of rivalry and cooperation. These are psychodynamic psychotherapy, which has its historical origins in Freud’s work and psychoanalysis, and behavioural psychotherapy, which involves an application of learning theory and stems from the work of Pavlov on conditioning principles. Here we are principally concerned with psychodynamic rather than with behavioural psychotherapy (though see p. 111 and p. 228). Basically the approach of the behaviourist was that of a physiologist or psychologist studying the patient from the outside. He* was interested in externally observable, and preferably scientifically measurable, behaviour and in manipulating (by suitable rewards and punishments) deviant or maladaptive behaviour towards some agreed goal or norm. Behaviour therapy has now been modified and developed and joined with cognitive science to form cognitive-behavioural psychotherapy. Over the past decade, despite the hybrid name, this approach has become less behavioural

* Where the sex of the therapist or patient is not defined by the particular circumstance described, he or she is referred to, for convenience, in the masculine gender throughout this book; such references should be taken to imply male or female.

and more cognitive, focused on inner states of mind and how cognitive processes influence behaviour. We discuss this on page 229.

The dynamic psychotherapist is more concerned with approaching the patient empathetically from the inside in order to help him to identify and understand what is happening in his inner world, in relation to his background, upbringing, and development: in other words, to fulfil the ancient Delphic injunction ‘Know Thyself’. Dynamic psychotherapy has been the major influence in the field of mental health, and has appealed more to doctors, social workers, and those psychologists immersed in the complexities of relationships with patients or clients, and to patients wishing to understand themselves and their problems rather than to seek symptomatic relief alone. Sutherland (1968, p. 509) wrote:

By psychotherapy I refer to a personal relationship with a professional person in which those in distress can share and explore the underlying nature of their troubles, and possibly change some of the determinants of these through experiencing unrecognized forces in themselves.

(Those unclear about the respective training and role of psychiatrists, psychologists, psychoanalysts, and psychotherapists will find them briefly described in the Appendix).

Perhaps what is more surprising is that dynamic therapy and cognitive-behavioural therapy share aspects of theory and practice themselves and overlap with other therapies. So before we move on it is worth commenting on the increasing integration of psychotherapy that has taken place over the past few years. Despite the tensions between schools of therapy, integration has taken place within theory and everyday clinical practice. Theory has become increasingly intertwined, with concepts being borrowed or even appropriated from one therapy to another; different therapies are often organizationally integrated, for example offering family therapy with cognitive therapy for a patient with schizophrenia, and practitioners are integrating techniques into their own amalgam to tailor the approach to the patient.

The phenomenal growth of psychotherapies is largely a manifestation of these integrative tendencies at their most promiscuous. In the 1960s there were about 60 different forms of psychotherapy, by 1975 there were over 125, by 1980 there were 200, and by the mid-1980s there were over 400 variants (Bergin & Garfield, 1994). Few, if any, of these new psychotherapies have received the systematic appraisal that is required in the present climate of evidence-based practice. Many use techniques from more than one theoretical orientation and are commonly described as ‘eclectic’ rather than integrative.

Theoretical integration has been formalized into hybrid therapies such as cognitive analytic therapy (CAT, see p. 230) or interpersonal psychotherapy (IPT, see p. 222), which explicitly bring together elements from other known therapies into new freestanding types of psychological treatments with their own methods and evolving traditions. CAT, which was originally devised as a brief therapy suitable for NHS practice and accessible for inexperienced therapists, explicitly combines cognitive elements such as diary-keeping and self-rating scales with an analytic attention to transference and countertransference. IPT was devised as a brief, manualized, and therefore researchable therapy for depression.

A further facet of integration in psychotherapy—which might be referred to as ‘integration in practice’—refers to the flexibility which is to be found in the practice of mature clinicians, whatever their basic training, in which they will often consciously or unconsciously bring in elements of technique or theory borrowed from other disciplines. Thus psychodynamic therapists present cognitive challenges to their patients, or make behavioural suggestions, while therapists with a cognitive-behavioural background, as their therapies extend in time, may well work with transferential aspects of their patients’ behaviour such as non-compliance with homework tasks or persistent lateness.

Despite this increasing unification of psychotherapies it will be our contention first that all forms of dynamic psychotherapy stem from the work of Freud and psychoanalysis, which has produced many offshoots, and second that there are aspects to psychodynamic therapy that are specific, singular, and unique. Jung and Adler broke away before the First World War to found, respectively, their own schools of analytical psychology and individual psychology. Between the wars Melanie Klein and Anna Freud, applying analytic ideas to the treatment of disturbed children, developed child analysis. During the Second World War, Foulkes and others explored the use of analytic ideas in groups and developed group psychotherapy. Since the last war further developments have included family, couple, and social therapy. Rogers in the Encounter Movement, developments such as bioenergetics, and other forms of humanistic and integrative therapy have been seeking new ways of encouraging direct interpersonal contact to help free people from a sense of isolation and alienation from themselves and others. (Some of the links between these developments are traced in the ‘family tree’ of Figure 10 on p. 223.)

However, despite their apparent diversity and different theoretical formulations within dynamic therapies themselves, we believe that all schools of dynamic psychotherapy hold in common certain key concepts. These basic concepts are briefly introduced now and each is expanded in later sections of Part I.

Basic concepts

People become troubled and may seek help with symptoms or problems when they are in conflict over unacceptable aspects of themselves or their relationships. This is contrasted with the traditional medical model where symptoms are viewed solely as an expression of disordered anatomy and physiology.

Aspects of ourselves which so disturb us that they give rise to anxiety or psychic pain may be consciously rejected, and become more or less unconscious. We all employ a number of defence mechanisms to help us deny, suppress, or disown what is unacceptable to consciousness; these may be helpful or harmful.

Unacceptable wishes, feelings, or memories may arise in connection with basic motivational drives. The different psychodynamic schools may disagree over how to categorize human drives or as to which are the more important and troublesome: for example, those associated with eating, attachment, or sexual or aggressive behaviour. The central importance of conflict over drives and their derivatives remains.

Again, although phases of development have been conceptualized in a number of different ways, it is widely agreed that how we handle our basic drives begins to be determined in infancy by the response of others to our basic needs, our urges, and our states of mind. This is commonly at first mother, but subsequently others of emotional significance (father, siblings, teachers, etc.) have increasing influence, although how we respond to these people may be partly determined by the earlier pattern of interaction between mother and child. The developmental understanding of the interaction between mother and child has flourished as attachment theory, which now forms an increasingly important aspect of psychodynamic theory and practice.

It is in models of the mind, or theorizing about the structure of the psyche, that greatest disagreement has arisen. Freud revised his theories several times. At first he saw the psyche simply in terms of conscious and unconscious levels; later he introduced the concepts of super-ego, ego, and id. In more anthropomorphic terms Berne (1961) has written of the parent, adult, and child parts of each one of us. Yet running throughout is the idea of different psychic levels, with the potentiality of conflict between them.

Inevitably models of the mind have become mixed, although authors continue to emphasize particular elements of a model, with some concentrating on ego function and others emphasizing unconscious process. These differences are not necessarily oppositional. No single theory adequately explains all aspects of human function. One model that has had considerable influence both within and without psychodynamic therapy is object relations. Despite the harshness of the term, objects are essentially mental representations of current and past relationships and the emotions associated with them. But percolating the model yet again is the idea of conflict within or between representational ‘objects’.

Aspects of the therapeutic relationship will be the last of the theoretical principles dealt with, and it naturally leads us on to the area of practice. We will distinguish between the therapeutic or working alliance, transference, and countertransference.

HISTORICAL BACKGROUND TO DYNAMIC PSYCHOTHERAPY

Before developing each of these concepts further, let us take a brief look at the historical background, where we are much indebted to Whyte (1962) and Ellenberger (1970). Although it might be broadly true to say that all modern forms of dynamic psychotherapy— whether psychoanalysis, individual or group psychotherapy, or family or marital therapy—stem from the work of Freud and others at the turn of the century, it would not be true to say that Freud ‘invented’ psychotherapy.

The idea of a talking cure through catharsis of feelings is at least as old as the Catholic confessional, and current idioms such as ‘getting it off your chest’ testify to the widespread belief in its value. A work on Aristotle’s concept of catharsis was being much talked of in Vienna in the 1880s and may have influenced Breuer and Freud.

Nor is there anything revolutionary in the idea that we are often in conflict with our feelings, wishes, and memories. In 1872, a year before Freud entered university, Samuel Butler (1872, p. 30) wrote:

There are few of us who are not protected from the keenest pain by our inability to see what it is that we have done, what we are suffering, and what we truly are. Let us be grateful to the mirror for revealing to us our appearance only.

Writers down the ages, who have attempted to penetrate the complexities of human motivation, have known this intuitively. Shakespeare, for example, recognized unconscious conflicting wishes in King Henry IV Part II:

PRINCE: I never thought to hear you speak again.

KING: Thy wish was father, Harry, to that thought.

Pascal (1623–1662) in his Pensées knew that ‘The heart has its reasons, which reason knows not.’ Rousseau (1712–1778) wrote: ‘There is no automatic movement of ours of which we cannot find the cause in our hearts, if we know well how to look for it there.’ Writing in the 1880s Nietzsche anticipated Freud: ‘‘I did that” says my memory. “I could not have done that” says my pride, and remains inexorable. Eventually the memory yields’ (Whyte, 1962).

Freud’s achievement, combining the gifts of a great writer and scientist, was to address these ideas to a medical context, in such a way that they have since been given continuing and increasing, if at times faltering, attention. Yet as we have said, Freud did not invent psychotherapy any more than Darwin invented evolution. Darwin too had his forerunners; yet it was the added impetus of the evidence he collected for his new causal explanations of natural selection that gave a fresh weight to already current ideas on evolution.

Ellenberger (1970) has traced the ancestry of dynamic psychiatry from its origins in exorcism, and its evolution through magnetism and hypnotism. In primitive times, disease, both psychic and somatic, was commonly thought to be due to possession by evil spirits. Healing was expected to follow exorcism and such treatment was naturally in the hands of religious leaders or traditional healers, such as shaman, witchdoctor, or priest.

Alternatively, it was thought that disease might arise from ...

Table of contents

• Contents
• Foreword to the first edition
• Foreword to the second edition
• Foreword to the third edition
• Foreword to the fourth edition
• Prologue
• Part I Psychodynamic principles
• Part II Psychodynamic practice
• Appendix
• References
• Name index
• Subject index