# Exploring the landscape of the mind. An Introduction to Psychodynamic Therapy Janet Lee Bachant # Introduction - Ways of coping during childhood become structures. Mental organisation - Structures shape how people react and live. - Trauma is in the eye of beholder - "Listening for the footprints of the past" - - We want to promote integration within the patient, but too much emotional activation will stimulate defence. ^9b4b22 - "Too much emotional activation will stimulate defences, dissociative or splitting processes that inhibit integration. Working to help the patient identity, understand and integrate the smaller manifestations of their traumatic childhood experiences without being overwhelmed is a central goal of treatment. Think small, in fact, is a theme that will be repeated many times in many ways throughout the book." - page 10 - The therapy process, of creating a safe environment is step one. ^1b0291 - "Enduring the anxieties of exploring unknown territories and discovering that the enemy is within is a journal not to be taken lightly. It requires courage and a trusted guide to allow oneself to explore this terrain." - page 10 - Remember to cultivate a calm and steady stead to minimise the risk of emotional hijacking. Mindfulness. # Chapter 1: Therapeutic Attitudes - **Valuing the influence of the past.** - "William Faulkner (1951) observed, 'The past is never dead. It isn't even past'." - p17 - The past is pervasive and shaped by earlier experiences - thinking, relating, and feeling patterns are beyond conscious control... If we do not understand the past, we will touch surface content. - **Respect** ^9ca129 - Only the patient know themselves. Only they can walk in their shoe. - Don't think that we know what's best. - Respect the client's experience. - It takes time... expecting this work should be easy and quick is not respectful. - We cannot "fix" the client, it has to come from within patients themselves. - Giving advice and telling patients what to do can perpetuate patients positioning themselves as children and enacting childhood strategies. It can disrupt the learning process to use their inner selves to direct their lives. - **Curiosity** - We all have biases that cloud our abilities, - Having a sense of openness to the unvarnished experience of the other.. - Genuine interest in the truest picture of the patient's inner life allows patients to share parts of themselves that may never have been revealed to anyone - page 20 - Even the most minor details can stimulate associations, thoughts, feelings, and fantasies... enabling both to see patterns of organisation. - **Non-Judgementalness** - [[Carl Rogers]] - [[Book - On becoming a person by Carl Rogers]] - **Empathy** - Empathy is our first language. The first language is not the language of words, but that of nonverbal communication. - Distinguish between empathy and over-identification with the patient's experience: Empathy connects as a separate self. Boundaries are important. (Zwiebel, 2004) ^6e75b4 - - I am reminded by Juliana's word; we have to have an "edge of difference to make a difference", if we are too similar with the client, we are stuck. - **Genuineness** - It reminded me of Carl Rogers, "being congruent with my thoughts, feelings, and behaviour" - **Ability to accept limits** - We are not gods; we all have weaknesses. Accepting our limitations helps patients understand that we are all limited and that it is not shameful to acknowledge our limitations or mistakes. - We cannot help everyone. - **Flexibility** - Flexibility means we do not become fixed by following a "method", we allow ourselves to flow with the client. - **Courage** - It takes courage to go on this journey to explore the innermost recesses of mental life. - Patients' trauma histories can challenge our courage. It can be shocking, frightening, seductive, and disturbing.. it takes courage to stay with intense traumatic enactments. - It takes courage to be called out on our mistakes. - It takes courage to examine the intensity of a patient's feelings or actions, allowing them to develop their voice, which enables the patient's experience to be integrated into their sense of self. - It takes courage to allow ourselves to be used by another to serve their growth and development. ( suspension of ourselves to be the client's fantasy object) - It takes courage to connect. - "Like firefighters, we must have the courage to move towards the fires from which others run" - p27 **Hope** - ==Patients often come into therapy mired in helplessness (they felt as children)... that sense of helplessness can be enacted in therapy, leaving both participants with feelings of hopelessness.== - Identifying the causes of the hopelessness and how the patient maintains these feelings enable us to change our relationship with this debilitating feeling. - ==HOPE is grounded in our knowledge that when we work together to understand the patient inner and outer development, it will enable them to find new resources, make better decisions, change their relationships with inner tormentors. == # Chapter 2: Modes of Relating - [[Attachment Theory]] - The first thing we learn when we are born is how we are related to by other people. - Trust vs Mistrust - Is this world a safe place? - "Schore (2015) and Ginot (2015) contend that the hallmark of trauma is damage to the relational life and therefore the resolution of trauma must occur in a relational context." - THEREFORE, *HOW* the therapist relates to the patient is a critical factor in the success or failure of treatment. - p30 ## Ensuring Safety - Create a space that's safe for the client. - Be flexible, to accommodate the client's need for safety. - Give control to client to make decisions. - Offer observations without imposing solutions ## Working Collaboratively - "Generally speaking, relating to the patient collaboratively establishes a balance in which fantasy, transference, enactments, and deeply felt experience can emerge." - 33 - Take a collaborative approach, =="Not knowing is not the problem. Not being able to collaborate is. It is a critical problem in therapy because the patient, not the therapist, has the answers. Without this collaboration, the therapist is burdened with trying to accomplish something that is fundamentally beyond his or her reach."== - Collaboration can be a diagnostic tool - Patients may expect the therapist to be the authority who knows all the answers - Patients may be disconnected from themselves. - They may have grown up in familial sado-masochistic patterns of relating (they have to submit) - Patients may have fantasies that it's safer/secure to disconnect themselves from their inner lives. (p34) - The inability to form collaborative relationships may give us clues about the patient's history of relating. - Either patient talking non-stop, leaving no space for reflection (afraid that they may be criticised) - The patient immediately turns to the "expertise" of the therapist for safety-- they think that external authority has all the answers. ==Therapeutically, the therapist notices the obstacles to a more collaborative relationship, bringing attention and curiosity to exploring these processes== Remember: ==The most important aspect of working in collaboration with a client, we believe that the client is the only one who can direct their life. The patient is awakened to the idea that he can act on his own personal agency. And he being to see himself as an active agent of his own experience.== # Chapter 3 - Structuring the Therapeutic Situation - The process of therapy is challenging for both therapist and clients. The framework provide us a way to manage the intensity. - Robert Langs (1975) definition of the therapeutic frame: - The goal of this framework is to "maximize the emergence of the unconscious and the empowerment of the individual" - Not all interaction framework have that same focus, for example: Psychoeducational model, student/teacher interaction.. - Having a ritual (therapeutic process) act is a container of forces to protect us. #Ritual - The therapeutic process activates powerful emotional triggers in both participants, and therefore requires a. structure that can absorb and contain these forces. P40 ## Free Association - free association asks patients to verbalise what comes to mind without evasion or self-censorship, even if it involves thoughts, feelings and fantasies about the therapist. - Remember that this is a collaboration. - Many therapies are based on the patient's conscious awareness of their experience. Psychodynamic psychotherapy is organise around gaining access to fantasies, fears, wishes, and the powerful, emotionally driven representations of unconscious processing. - The analytic focus alternates between the focus on patient's inner world, and the focus on the interpersonal relatedness with the therapist and others. - [[202011011444 psychoanalysis, free association are deterministic]] - Free association allows the patients to view themselves as an object of the treatment. It's an active process enhances the development of observing, collaborative and integrative ego functions. ## Neutrality - It is a stance of the therapist to not judge and close off any room for "the more". We patiently listen and keep the space open. - "Because all relationships are ambivalent, and because many patients begin therapy thinking in black and white, leaving room for "the more" in our responses avoids premature closure and limiting understanding " - p41 - Sequence - Wait to see how the patient will start the session, there are reasons why certain topics, persons are brought up first. - Patient often speak of the parents with whom they are the least conflicted first. - p41 - ==The neutral therapist does not try to dictate the sequence or timing of issues, but instead, respect the patient's process= - Patient is the expert of their life. # Part 2 - Core Concepts in Psychodynamic Work ## Fantasy - "If we learn how to listen for fantasy and its transference manifestations, we can see indicators of mental organisation in every session" p65 - E.g "Lily made a mistake at work, she was anxious and worried that her boss will be angry (just like his father), she also feels sorry for everything as if she is always wrong" - Transference towards the therapist (seeing him as a father who is angry at her), reveal the fantasy underneath, which explains the complex developmental trauma. **The protective function of trauma is to prevent more hurt.** - "Trauma is designed by evolution to be remembered in order to prepare us for the world in which we live." - Trauma is activated by similarities, whether it's a smell, sight, location, etc depending on the strength of original trauma. - "It is activated by similarities of many varieties (sensory perceptions, structural similarities, temporal associations, etc) depending of the strength of the original trauma" - - p65 - ==a case study of Vita, looking for job, but to her, she was enacting her earliest traumatic memories of looking for the mother she had had and doubting that she would found her. == - ==This opened my mind! Situations, circumstances can be imbued with emotional meaning. A job search is more than a job search.== - traumatic fantasies can be re-enacted not only in interpersonal relationships, but also in how the patient relates to themselves and their world. - p68 **Trauma is not a one-off event that happened to people. It is a process within the person that now (unconsciously) perceive, organise, response to external world in the effort to self-protect?** - Trauma is not only an event that happens *to* people. It is, in addition, a *process living within the person* that generates mental and physical organisation. People organise the adversity they experience actively, though not always consciously, in ways that are mediated by emotionally based fantasies of self and others. **Listen not just the content but the process of trauma. How patients are making sense, using trauma.. do they repeat it, seek to master it, reinforce their helplessness etc** What are they doing with it? what kind of fantasy organises them.. # Chapter 6 - Transference / Countertransference #Transference #countertransference [[C202003231301 In intensive therapy work, watch out for transference and enactment processes]] [[C202003231323 Pay attention to process. Watch out for enactment.]] - In the therapeutic situation, transference activity is examined through emotional connectedness. It is not just talking about it. Participants can gain direct knowledge of the "pattern" of thoughts, feelings, defence and actions. (p72) - "What makes transference analysis so useful is that it brings mental organisation along with its affective component into the heart of the therapeutic process." p72 - When we analyse transference, we can uncover the patterns and can figure out how the person organises their inner world (fantasy, fears, wishes..) - ==Freud (1914) Remembering, Repeating and Working Through - =="the patient does not remember anything of what he has forgotten and repressed but acts it out. He reproduces it not as a memory but as an action: he repeats it, without, of course, knowing that he is repeating it (Freud, 1914, p. 150)"== - Transference engagements happen but we may not be aware of them. The key is to identify the enactment, and then use a nonjudgemental curiosity to open up the process. (p75) # Chapter 7 Resistance - The function of resistance: is to protect us from painful feelings, express or enact unconscious fantasies, preserve relationships,.. maintain psychological homeostasis, autonomy, and identity... (Adler and Bachant, 1998) - From early on, we form a mental framework that tries to make sense of the world. But this is dominated by right hemisphere emotional dominance and immature cognitive functions. - Working with resistance therefore is valuable because it points us directly to the patient's core issues. It maps the uncharted territory of the patient's fears, fantasies and conflicts. - p80 - Befriend the resistance. Appreciate the history (resistance is linked to trauma) - ![[C202003051320 Group supervision notes from 13 Feb 2020#^4d4500]] -- And the Self is wanting to have some control. - [[C20200323 Looking at what people are doing now, i wonder how much is related to compensatory reaction due to their past]] - We work to uncover their emotional investment in maintaining behaviours they say they want to modify. (paradoxical, we keep doing the things we don't want) - What emotions are being warded off? - What protections are invoked? - What does the belief in a guilty self-purchase for the patient? - How does the patient view the therapist's behavior? - (We talk about secondary gain.) ## Part 3 - Therapeutic Skills: Listening for the footprints of the past - Listen with humility and respect is important. - Patient who have experienced childhood trauma have altered psychological equilibrium and afraid of losing control and autonomy. Important to help them feel safe. - [[sense of control]] - [[🏠 Trauma]] # Chapter 11 Listening for Defense [[202403271102 Labelling behavior as self sabotaging is a disservice to the process]]