Psychodynamic Theories and Concepts - Case Study Example

.   How psychodynamic theories informed my use of counselling skills in an exchange I had with a 'client' in my classroom As many as 19.2% new mothers may show major or minor depression post partum (natal) (Beck, 2006, p42). She emphasised appropriate identification of post natal depression (PND), since there are many terms used for similar conditions such as baby blues, post natal psychosis etc. My client Julia’s case presents depressed mood, lack of pleasure in enjoying the baby and motherhood, improper guilt, psychomotor dysfunction and vague thoughts. She may probably be having insomnia also and is diagnosed as having PND. In the present article, I have made an attempt to resolve Julia’s dilemma through psychodynamic theories and concepts. The psychodynamic theory focuses on understanding unconscious mental processes that cause psychological dysfunctions. The major postulates of this theory are: most of the mental processes such as thoughts, feelings and motives are unconscious i.e. people may behave or develop symptoms in a way that is inexplicable to them. The mental processes may act in parallel sentimental and inspiring manner. Thus the person may have opposing feelings towards the same individual which pulls him in opposite direction and leading to a compromise or defensive situation (Huprich, 2008, p5). Freud defined unconscious as having two types: preconscious which can be made conscious when attention is focused on it. While truly unconscious are those mental contents which are unacceptable and hence are repressed. These can not be brought to the awareness easily. The unconscious does exist is proved by dreams which are expression of our suppressed wishes and desires. The psychodynamic therapist views the symptoms and behaviour as reflections of defences against repressed unconscious processes (Gabbard, 2005, p8). These unconscious mental processes would cause distress if become conscious. The psychological mechanism that keeps these highly disturbing and distressing wishes or fears unconscious is known as repression. Repression is only one way to keep disturbing processes unconscious and avoid the distress. Thus repression is a kind of defense to avoid disturbing the psyche (Schwartz et al, 1995, p6) The psychodynamic theory focuses on childhood experiences as childhood is the crucial period for personality development which shapes the later social relationships. Mental understanding of self, others and relationships determine peoples reaction and psychological influences towards others. Personality development is not only managing aggression and sexual feelings it is also moving from immature social dependence to mature interdependence. It is appropriate to know here that how our feelings and acts coordinate or become discordant (Huprich, 2008, p5) According to Freud the psychological structure of mind includes id, superego and ego. Id resides in the unconscious and represents urges, drives and impulses. It is pleasure seeking and aggressive mental structure looking for an object to gratify its desires. (Huprich, 2008, p19). The superego is that part of mind whose foundation is laid on social norms and appropriateness. It works on unconscious level but its contents may become conscious. A conflict develops when desires of id are suppressed by the norms of superego. The ego is the part of mind where consciousness occurs. . The great ability of ego is to identify reality and act accordingly (Huprich, 2008, p20-21). To identify problematic areas of Julia’s past and relating these to present perspective, we (me and Julia) begin to sort these out. The conversation between me and Julia during first two sessions is as follows: Me: How do you feel now that there is a baby in the house? Julia begins crying and does not respond. Me: Are you all right! Julia does not respond but wipes off her tears Me: Is the baby fine? Julia tries to stop her sobs and nods her head in affirmative. After some time she says: Baby is keeping me isolated as he is the center of attention for Romnauld, I feel left out and unwanted as other woman (the crying begins again) Me: Why other woman? How did you get this idea about the baby? Baby is your part and belongs equally to both the parents. Julia: When I first met with Romnauld, he was with his girl friend but after our meeting he left her for me. I realise that Julia was the ‘other woman’ in the past and still has the guilt in her unconscious mind. I find that the causes of her depression are unjustified guilt and fear of being other woman in Romnould’s life because of the baby. She fear abandonment any time and is jealous of the baby. Her somewhat maladapted concept of mother-child relationship, that seems rooted in her own childhood experiences, making her take the baby as liability. All these aggravated post natal which already is a well known depression causing period. I need to explore her developmental years and relationship with her own mother, father and sibling. To begin this I need to create an appropriate environment. I understand that both therapist and client meet with personal expectations and aims. As a result in their relationship motivations and needs are incorporated and such relationship often become intimate with the client feeling anger, envy, love and sexual attraction towards his therapist. In the course of therapy the relationship becomes central to outcome of therapy and client shows emotional changes towards it. This bonding between client and therapist is known as transference. It is basically the phenomenon through which old fantasies of client are aroused as she takes her therapist as some earlier person. The feelings from the past are transferred to person in front of client, the therapist. These feelings are generally the reactions that occurred in the early childhood with important others (Dryden, 2002, p30). Julia seems eager to be unburdened of her conflicts and despite her depression cooperates fairly well. She comes timely for her sessions. To strengthen the positive transference, I decide to keep my intervention reflective. As the sessions proceed the client begins to treat therapist as lover or a parent. Thus in the exchange the past relationship come alive here and now. It is necessary for me to accept Julia unconditionally to create a positive transference from her side. I also make it to remember well what she said in the last session so as to reflect well on her new piece of information (Jacobs, 2004) I had shown interest in her story and understanding of her problems. I asked her to tell more without actually ever interrupting her or asking too many questions at a time. I also allowed her to cry for sometime before repeating my question gently. It is also likely that there will be reaction from me to her as well (counter-transference). Though the Freudian view considers it as improper emotional response, in the therapist, to the transference and expectations of her client, however, I support Kleinian views that takes counter-transference as source of all feelings in therapist about her client. Counter-transference will be used by me to understand unconscious communications of patient (Dryden, 2000, p31). My decision to explore Julia’s early developmental years, her relationship with parents and /or possibility of sibling rivalry is well supported by classical psychodynamic theories and otherwise also the childhood development is the focus of psychodynamic therapy. Her rivalry with the baby may be result of an immature past asserting itself in her psyche. I would take help from established theories in this context and begin with oedipal complex theory which is studied in considerable detail for a male child but is applied to female child with a little variation. The age 3-5 years was called oedipal age by Freud. The children wish that the rival (parent of sibling) is out of the way so that they can enjoy their intimacy with mother or father. This time of child hood is the time of intense love, hate, rivalry and shapes the later personality. But at this time the mother-child frame changes to a triadic frame i.e. child becomes rival of his father to get full attention of mother. For a male child the first love attention is his mother and he tries to be close to her, touch, caress and sleep with her. Since the father interferes with his plans, the child becomes almost brutal towards the father. If the life goes on normally the conflict withers. Since these desires inculcate guilt and fear of retaliation by father and anxiety results in child from that fear. The anxiety is mainly the castration by father. To protect himself from this punishment the boy let go of his sexual attachment to mother and identifies himself with father. This identification with his probable aggressor is a strategy to be like his father so that he can get a woman like his mother. The retaliatory father is assimilated in the unconscious as superego. But, if the rival parent or sibling is separated or dies the child becomes fearful of his own jealousy now that his wishes have come true. As a result the child becomes neurotic as he is not able to grow out of childhood fantasy and consequence of it. The neurotic child fails to distinguish between fantasy and reality. Disturbances in preoedipal/oedipal phases child-parent relationship cause psychoses with inability to cope up with separation or loss, depression and anxiety (Bateman et al, 2000; Gabbard, 2005). It is difficult to explain initial psychological development of females in same way but it occurs nevertheless, in same manner. In boys the Oedipus complex is resolved by castration complex while in girls it is disseminated by awareness of castration. In the preoedipal phase little girl feels just like the boy till she discovers penis. This makes her feel inferior and envious. She blames her mother for this inferiority and turns to her father as her love object (Gabbard, 2005). It is likely that Julia was separated from her rival before she could overcome the rivalry and her oedipal phase did not wither. It is also likely that she has a male baby and between baby and Romnauld she is having anxiety and fear of being abandoned because of her genital inferiority. The relationship with her parents would reveal whether they were separated when Julia was passing through her oedipal phase as a result she might have been separated from her first love interest, her father rather abruptly. The presence of baby brings the same immature past again by separating her from exclusive attention of Romnauld. In case she has a female baby then the childhood rivalry due to a sibling or even her mother who would have been closer to her father and made Julia feel as ‘the outsider’ Klein’s paranoid-Schizoid and Depressive phase theory would also address my requirements well. The infant’s first feelings are of good and bad only. He idealises his mother while at some moments the same object (mother) becomes horrible to him. This is Klein’s paranoid-schizoid position. The hunger creates great distress for the baby while sated hunger is greatest pleasure. The baby identifies his mother in parts not as whole individual. She is the breast that feeds and the arm that rocks. With great depression and pain the infant later learns that world is a mixture of good and bad people and that same person may be good as well as bad. The mother who is nourishing and comforting may become a centre of attack by the loving and hating ego. It is a split condition in which good things are dominant. This process is necessary for integration in growing years. If, however this process is disrupted the anxiety and hostility become intense while confronting reality becomes painful. The successful integration of paranoid –schizoid phase occurs through splitting, projection and introjection and leads to next phase, the depressive phase. Baby begins to recognize his mother as whole object, separate from him. The anxiety changes from paranoid to depressive stage now that baby has cut away the mother from himself. These stages are natural development of healthy psyche (Dryden, 2002). Unsuccessful working through the depressive phase causes struggle in adult life. The person is unable to separate between inside and outside and feeling of inappropriate guilt result as a defence mechanism to survive intense sadness. Julia nurses recurrent guilt of being the other woman and therapist need to rework her through the depressive phase and resurrect her internal object. The knowledge of her childhood would be required to know the loss of parent and /or sibling rivalry for getting parental affection and failing in it. Bowlby’s attachment theory would help me understand Julia’s difficulty in maintaining healthy relationships. The infant attachment patterns sometimes persist till adulthood as a result leading them to have anxious relationship. It is a factor making them vulnerable for depression or other psychiatric illnesses. The anxious attachment makes them possessive and needy for the company of their partner and this is insecure attachment (Holmes, 1993). Bowlby tried to decipher the nature of parent-child bond through his attachment theory. Attachments are secure and insecure. The former gives a feeling of safety and security while the latter is a mixture of intense feelings such as intense love and dependency, fear of rejection, irritability and vigilance. When there is lack of security in attachment, the wish to be close to attachment figure and punish it even if a hint of abandonment is perceived. Bowlby posited that separation of child from parent is breaking a fundamental and fragile bond. The separated child feels extreme anguish and pain leading to neurosis in adolescence and mental illness in adulthood (Holmes, 1989, p62). Bowlby makes clear departure from the theories of many psychoanalysts. According to him the affectional bonds between two persons are not only formed for fulfillment of food and sex requirement. Since many young become attached to a mother figure though it does not feed them, similarly two adults form a bond without any sexual relation. However, a sexual relation may happen without actually forming a bond. The breaking of affectional bond in childhood also leads to difficulty in maintaining such bonds as adults. A child separated from mother for 2-3 weeks initially cries for her but soon he becomes adjusted to live without her. When the mother returns, the child does not rush and cling to her rather he just looks through her. It takes time for re-formation of attachment bond. But when it is reformed it is much stronger (Bowlby, 1989, p70). Exploring Julia’s childhood would provide information whether she faced breaking of affectional bond in some way in early childhood and as result developed insecure and possessive relationship with Romnauld. Unlike Freud Winnicot believed that we are not influenced by our unconscious always but only minimally if we develop a healthy ego. The muddled emotions of infancy are changed to ego when infant builds a successful relationship with the mother. Those who remain deprived from developing a healthy ego are dominated by unconscious. He coined the term ‘good enough mother’ for the mother who understands and responds to her child well. If the mother does not respond to the child well the healthy ego does not develop instead the child and later the adult hide behind a ‘false self’. He can not assert himself but passively carry out other’s wishes (Jarvis, 2000) . The therapist needs to provide a ‘holding and maturational environment’ to resume the deficient processes with such patients. The therapist becomes a mother figure by giving the client emotional reliability, availability, non interference and at the same time respecting her autonomy and individuality (Messer & Warren, 1998). Relationships are founded on trust and attachment. The major theme for relationship is triad which is mutuality and interdependence or complementarity. We accept a person not only because of his similarities with us but also with his differences. (Jacobs, 2005). I peep into the past of my patient and try to restructure it for balanced present living. The childhood formation of psyche, understood through classical theories, is going to be very useful to my interpretations and resolving Julia’s depression and anxiety. References Bateman, A, Brown, D & Peddar, J 2000. Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice. 3rd Ed, Routledge Beck, CT 2006. ‘Postpartum Depression. AJN, Vol. 106, no. 5, pp40-50. Bowlby, J 1989. The Making and Breaking of Affectional Bonds. Routledge Dryden, W 2002. Handbook of individual therapy, 4th Ed, SAGE Gabbard, GO 2005. Psychodynamic psychiatry in clinical practice, 4th Ed, American Psychiatric Pub Holmes, J 1993. John Bowlby and attachment theory. Routledge. Huprich, SK 2008. Psychodynamic Therapy: Conceptual and Empirical Foundations, CRC Press Jacobs, M 2004. Psychodynamic Counselling in Action. 3rd Ed, SAGE Jacobs, M 2005. The presenting past: the core of psychodynamic counselling and therapy, 3rd Ed, McGraw-Hill International Jarvis, M 2000.Theoretical approaches in psychology. Routledge Messer, SB & Warren, CS 1998. Models of Brief Psychodynamic Therapy: A Comparative Approach. Guilford Press Schwartz, HJ, Bleiberg, E & Weissman, SS 1995. Psychodynamic concepts in general psychiatry. American Psychiatric Pub Read More