 \200 (because of psychomotor retardation); (where treatment of organic pathology is acute suicide risk. Goals of assessment The assessment of a patient for psychotherapy has three major goals: \200 \200 want from therapy)? What does the patient expect (or Obtaining a careful history/narrative of the problem from the patient (do they need therapy?) Establishing whether the patient can form a therapeutic relationship and make use of the type of therapy being potentially offered. Different therapies will have a varying focus in the initial assessment, e.g. psychodynamic assessments will often focus more on relational aspects of the patient \200\231s life wher eas cognitive behavioral therapists may concentrate more on the (A)ntecedents, (B)ehaviours /(B)eliefs, and (C)onsequences of the patient \200\231s behaviors or beliefs. Psychological factors in assessment for psychotherapy \200\230Psychological-mindedness \200\231 Refers to the capacity for insight and to unders tand problems in psycho- logical terms: \200\230can the patient think about their thoughts ? \200\231. If this is lacking, a supportive method may be preferred over a cognitive or ex ploratory method. Motivation for insight and change Many patients (and trainees!) do not want to \200\230get better \200\231 or change. Often we are more comfortable playing by the rules of the game we know, even if this means we \201 nd ourselves caught in dif \201 cult situations, rat her than learning a new game. An important part of assessment is to establish whether the p otential patient is willing to take responsibility for their situ- ation and use therapy as a means of changing it. Adequate ego strength and reality testing Important when considering exploratory psychother apies, especially those based on exploring transference dynamics. Includes the ability to s ustain 20_Semple_Chap20.indd 822 12/7/2012 4:32:53 PM ASSESSMENT FOR PSYCHOTHERAPY 823 feelings and fantasies without impulsively acting upon them, being over- whelmed by anxiety , losing the capacity to continue the dialog, or treat- ing \200\230as if \200\231 situati ons as though they \200\230actually are \200\231 real. Ability to form and sustain relationships Where there is inability to enter into trusting r elationships (e.g. in para- noid personality disorder) or where there is inability to maint ain relation- ship boundaries (e.g. in borderline personality disorder), this may preclude exploratory methods. Able to tolerate change and frustration As with any potentially powerful treatment, psychot herapy has the poten- tial to exacerbate symptoms, particularly when maladaptive coping mec ha- nisms are examined and changed. Selection of psychotherapeutic method Local availability In practice, often the main determinant of therapy choice is local avail abil- ity and the practical availability determined by the length of the waiting list. The waiting times associated with most forms of therapy should encour- age all practitioners to exercise care in patient referral. Practitioner experience and view of modality Where the treating psychiatrist also provides the psychotherapy, his or her area of expertise may determine choice of psychotherapeutic m ethod. Illness factors Varying illnesses and states of mind have been shown, within the evidence b ase, to respond differentially to different treatments. Patient choice Patients may express a preference for a particular therapeutic model because of previous positive experience or having read or been told about the approach. A method w hich \200\230makes sense \200\231 to the patient given their understanding of their sympto ms is often preferred. 20_Semple_Chap20.indd 823 12/7/2012 4:32:53 PM CHAPTER 20 Psychotherapy 824 A brief history of Sigmund Freud Freud remains far and away the world \200\231s best-known psychiatrist and his image, of a scholarly, bearded man sitting behind a distressed patient lying on a couch, is many lay-people \200\231s archetype for our profession. He made a hug e contribution to our understanding of the mind, but many of his ideas are now so much a pa rt of our general view of the world that it is easy to overlook the breakthroughs they orig inally were. He was born in 1856 in Moravia (now part of the Czech Republic, but then part of the Austro -Hungarian Empire). He moved to Vienna when he was a child and lived there until his last y ear. On entering medical training he was in \202 uenced by scienti \201 c empiricism \200 \224the belief that through careful observation the un-understandable could be understood. On quali \201 cation he began laboratory work on the physiology of the nervous system unde r Br cke, later entering clinical medical practice after his marriage in 1882. He chose ne urology as his specialty and received a grant to study at the Salp tri re in Paris, where he was exposed to the ideas of Charcot, who interested Freud in the study of hysteria and the use of hypnosis. In Paris with Charcot, and later in Nancy with Li bault, he studied t he behav- iour of hysterical patients under hypnosis and developed his ideas of the unconsc ious mind and its role in normal and disordered behavior. Returning to Vienna, Freud began collaboration with Josef Breuer on the study of hysteria. The subsequent development of psychoanalysis was prompted by the case of Anna O., treated b y Breuer between 1880 and 1882. This patient, a 21-yr-old woman (real name Bertha Pappenhei m), presented with a range of hysterical symptoms including paralysis, visual loss, cough, and abrupt personality change. These symptoms had devel- oped while her father was terminal ly ill. Breuer observed that her symp- toms resolved during hypnotic trances. Breuer also n oted that not only did the symptoms recur after the sessions ended, but that after he termi - nated the treatment relationship she suffered a full-blown relapse. Breuer wrote up the c ase after discussing it with his younger colleague. Later they published Studies in hysteri a, detailing their ideas on the etiology and treatment of hysterical symptoms. This book po stulated that trauma is unacceptable to the patient and hence repressed from conscious memo ry. This repression produces an increase in \200\230nervous excitation \200\231 \200\224wh ich is expressed eventually as hysteria \200\224with a conscious remnant, often in a disgui sed form, which can be accessed and resolved during hypnosis. Freud explored these ideas during his clinical practice in the 1890s, using a variety of me thods to uncover the repressed memories. Later he developed the technique of free associati on, where the patient is encour- aged to say whatever comes to mind. Experience in the 1890 s led Freud to develop the ideas of repression of unacceptable memories and their expressio n as hysterical symptoms. The initial memory was generally of a sexual nature. At \201 rs t Freud thought this was a real, remembered assault, but later realized that in the majorit y of cases the patients were describing a sexualized fantasy towards parental \201 gures. Freud described these ideas in his most famous book, The interpretation of dreams, publish ed in 1900. It described the basis of his psychoanalytic technique including analysis of th e content of dreams, descriptions of defense mechanisms, and his 20_Semple_Chap20.indd 824 12/7/2012 4:32:53 PM A BRIEF HISTORY OF SIGMUND FREUD 825 topographical model of the mind. Freud \200\231s early insights tended to come directly fro m clinical experience, particularly from patients with hysteria. His later ideas were more theoretical and aimed to develop a model of the normal and abnormal development of mind thr ough psychoanalytical ideas. His drive theory postulated the existence of basic drives, whi ch included the libido, the sexual drive, and the eros and thanatos (the drives towards lif e and death). He described the pleasure principle, the drive to avoid pain and experience p leasure, and its modi \201 cation through the real- ity principle. In 1905 he published Three essays on the theory of sexuality, describing his theories regar ding childhood development including the ideas of develop- mental phases and the Oedipal an d Electra complexes and their relation- ship with the development of adult neuroses. The eg o and the id, published in 1923, saw the replacement of the topographical with the structur al model of the mind. He described his theories of ego psychology and the production of anx iety symptoms in Inhibitions, symptoms and anxiety in 1926. Although he recognized the impo rtance of unconscious defenses in response to anxiety, the \201 rst systematic account of these mechanisms was written by Freud \200\231s daughter Anna in The ego and the mechanism s of defense in 1936. Freud \200\231s repeated revision of his own theories was mirrored by repeated disagreements and splits in the psychotherapeutic movement and the formation of s eparate psychotherapeutic \200\230schools \200\231, usually strongly associated with one c harismatic individual. Freud died from cancer in England in 1939 after \202 eeing Vienna following the rise to power of the Nazis. His daughter Anna continued to re \201 ne and pu blicize her father \200\231s work, which has recently been retranslated and reprinted in fu ll. 20_Semple_Chap20.indd 825 12/7/2012 4:32:53 PM CHAPTER 20 Psychotherapy 826 Other pioneers of psychoanalysis Anna Freud (1895 \200\2231982) Although Freud recognized t he importance of unconscious defenses, the \201 rst systematic account of these mechanism s was written by his daughter Anna in The ego and the mechanisms of defense in 1936. She al so helped to develop child psychoanalysis and play therapy. Carl Jung (1865 \200\2231961) Associated with Freud until their views over the sexual etiol ogy of the causes of neuroses differed and he founded his own school of analytic psychology . Key concepts include the \200\230collective unconscious \200\231 in which humanity \200 \231s shared mythological and symbolic past is represented in the unconscious mind of an in dividual by symbols called \200\230archetypes \200\231. He also described 16 personality t ypes, including differentia- tion between \200\230introverted \200\231 and \200\230extrov erted \200\231 types. Erik Erikson (1902 \200\2231994) Expanded Freud \200\231s developmental theory by explainin g that there were not only sexual con \202 icts at each phase but also a con \202 ict rel ated to how individuals adapt to their social environ- ment. Described eight stages of psyc hosocial development of the identity throughout the lifespan, characterized by the followin g con \202 icts: trust vs. mistrust (infancy), autonomy vs. shame and doubt (early childho od), initia- tive vs. guilt (play age), industry vs. inferiority (school age), identity vs. role confusion (adolescence), intimacy vs. isolation (early adulthood), genera- tivity vs. stagnation (middle adulthood), integrity vs. despair (old age). Alfred Adler (1870 \200\2231937) Theorized that all people are born with an \200\230infe- riority complex \200\231, an unconscious sense of inadequacy, which may lead them to over-c ompensate. Disagreed with Freud \200\231s emphasis on sexuality in the development of both normal personality and the neuroses. Melanie Klein (1882 \200\2231960) A controversial \201 gure and one of the founders of th e object relations school. She demonstrated that a child \200\231s unconscious development can be understood by observing the child at play \200\224felt to be analogous to free assoc iation. While her resulting developmental theories are not widely accepted by contemporary psychologists, play therapy is still commonly practiced. She emphasized primitive defense m echanisms such as projection/projective identi \201 cation, introjection, and splitting as well as the emotions of love, hate, anger, and envy. Donald W. Winnicott (1897 \200\2231971) Another object relations theorist who studied the i nfant \200\231s growth of a sense of self. He described the \200\230transi- tional object \200\231, which was an item such as a teddy or blanket that aided the infant \200\231s tran sition to independence by standing in for the mother \200\223infant object relationship. He described the \200\230good-enough mother \200\231 to refer to the environment needed for normal psychological development. He also developed the concept of true and false selves \200\224the true self responds instinctively and spontaneously, but when parenting is not \200\230good enough \200\231 a false self-persona may develop to maintain relatedness with the parents while protecting the more vulnerable true self. Wilfred R. Bion (1897 \200\2231979) A pioneer in thinking about groups whose \200\230basic assumptions \200\231 describe three ways in which groups may function: 20_Semple_Chap20.indd 826 12/7/2012 4:32:53 PM OTHER PIONEERS OF PSYCHOANALYSIS 827 dependency, \201 ght \200\223 \202 ight or pairing. He moved away from emphasizing the c ontent of patients \200\231 narratives to thinking about how we structure the world around us through our thinking, and how this in turn allows our internal worlds to develop. Carl Rogers (1902 \200\2231987) Worked on therapeutic technique. He conceived \200\230clie nt-centered therapy \200\231. He felt that the therapeutic attributes of genu- ineness, unc onditional positive regard, and accurate empathy could help patients achieve what he called \200\230self-actualization \200\231, a complete sense of self, which was bene \201 cial to their recovery. John Bowlby (1907 \200\2231990) Worked on attachment theory, which has been developed from ethological studies and empirical research in humans such as observing infants \200\231 beh aviors when separated from and then reunited with their mothers. Attachment theory stresses the importance of the feelings of closeness and security an infant develops with the careg iver as well as the role the caregiver plays in helping the infant to form these feel- ings . The child can, if such feelings have developed, then use the mother as a \200\230secure base \200\231 from which to explore and then return to when their anxi- ety increases. Bowl by delineated four different attachment styles which have been found to be transmitted from parent to child with reasonable reliability: secure, ambivalent, avoidant, and disorganize d. 20_Semple_Chap20.indd 827 12/7/2012 4:32:53 PM CHAPTER 20 Psychotherapy 828 Basic psychoanalytical theory Topographical model of the mind In The interpretation of drea ms Freud theorized that the mind consisted of the unconscious, the precon- scious, and the conscious. Only those ideas and memories in the conscious mind are within awareness. The pr econscious contains those ideas and memories capable of entering the conscious mind. The pr econscious per- forms a \200\230censorship \200\231 function by examining these ideas and memories and sending those which are unacceptable back to the unconscious ( \200\230repres- sion \200\231). The unconscious mind acts according to the \200\230pleasure principle \200\231 \200\224 the avoidance of pain and the seeking of grati \201 cation. This is modi \201 ed by the \200\230reality principle \200\231 of the conscious mind: that grati \201 cation often must be postponed in order to obtain other forms of pleasure. Freud \200 \231s psycho- analytic techniques would attempt to interpret unconscious content based on a ccess to preconscious content, such as free associations, the content of dreams, transferen ce, jokes, and \200\230parapraxes \200\231 (b p. 837). Structural model of the mind Freud recon \201 gured the topographical model in light of his clinical experience. In the struc tural model an infant \200\231s mind was comprised of id ( \200\230the it \200\231, which w ishes to pursue its own desires regardless of the constraints of morality or external reali ty) which is entirely unconscious. As time goes on and development occurs the mind further differentiates into the ego and then the superego. The ego ( \200\230the me \200\231) is mo stly conscious, emerges during infancy, and is the part of the personality which negotiates between the \200\230three harsh masters \200\231: the desires of the id; the hold of real ity; and the superego. The superego (the \200\230conscience \200\231) is the conscious and unconscious internalization of the morals and strictures of parents and society, which pro vides judgements on which behaviors are acceptable and which are not. When the ego is unabl e to successfully moderate between the id and superego it may defend the individual \200 \231s sense of self by repressing the impulse to the unconscious, where its presence may pr oduce disturbance. Alternatively, the ego may be tormented by an over-harsh superego. Drive theory Freud postulated the existence of basic drives, which included \200\230libido \200\231, the sexual drive (b p. 832), which made up part of \200\230eros \200\231, the l ife drive, in opposition to \200\230thanatos \200\231, the drive towards death. He describ ed the pleasure principle, the drive to avoid pain (or unpleasure) and experience pleasure as well as its modi \201 cation through the reality principle. Additionally he described t he repetition compulsion \200\224the ten- dency of people to compulsively repeat their earl y experiences through- out their lives. Transference reactions Transference The unconscious development, in the patient, of feeling s, thoughts, attitudes, and patterns of behavior towards the therapist which recapitulate e arlier life relationships, most usually the patient \200\231s relation- ships with their pa rents. Transference is viewed as a defense against the reality of relationships with others . The analysis of the transference is a prime feature of psychoanalysis. 20_Semple_Chap20.indd 828 12/7/2012 4:32:53 PM BASIC PSYCHOANALYTICAL THEORY 829 Countertransference Describes the equivalent reaction in the thera- pist towards the patien t, though this concept has now been extended by some schools to encompass all thoughts, fee lings, imagery, etc. that patients evoke and engender in therapists. The examination of tra nsfer- ence and countertransference is a central part of dynamic psychothera- pies and guid es diagnostic formulation and the exploration of the patient \200\231s pathology. Thought processes Dreams were felt by Freud to be the product of the unconscious mind as th ey occur when the internal censor is relaxed by sleep. They allow insight into unconscious thought process which is described as primary process thinking. In this form of thought the re is no negation (yes and no can mean the same thing), there is no sense of time, ideas ca n be condensed into single symbols, and it is primarily symbolic and non-linear. Secondary process thinking, in contrast, is found within preconscious and conscious parts of the mind and is orientated to time, operates in a linear fashion, is predominantly word-orientated, and negation applies (i.e. yes is not no). Psychoanalytical techniques Free association The fundamental rule within psychoanalysis is for the patient to say whatever comes into his mind and then associate from this. Resistance Blocks to free association, e.g. forgetting or changing the sub- ject, demonstra te where resistance and hence psychological problems are present, i.e. the mind says \200 \230don \200\231t even go there! \200\231. These points of resist- ance are to be analyzed, thus making the unconscious conscious, or more famously \200\230where it is, let ego be \200\231. Evenly suspended attention As a corollary to the patient \200\231s free association the ana lyst is asked to maintain themselves in a state of \200\230evenly suspended \200\231 atten tion to allow themselves to hear both what the patient is saying and what they are not. Defense mechanisms Freud conceived the idea of repression acting as a defense to prevent un acceptable thoughts from reaching conscious awareness. Subsequently other defense mechanism s were described, viewed as developing to pre- vent con \202 ict between the conscious min d and unconscious desires and developing in the course of normal maturation. Mental disorde r can be characterized by the persistence of primitive defense mechanisms, with immature de fenses seen in early childhood, mental illness and personality disturbances and neurotic de fenses seen in older children or adults expe- riencing stress or anxiety. Mature defenses a re seen in functioning adults. A full list of defense mechanisms is given on b p. 830. 20_Semple_Chap20.indd 829 12/7/2012 4:32:54 PM CHAPTER 20 Psychotherapy 830 Defense mechanisms Primitive defense mechanisms Denial Remaining unaware of dif \201 cult events or subjective truths which are too hard to accept by pushing them into the unconscio us. Introjection Our perceptions of signi \201 cant \201 gures in our lives are internal- iz ed where they form the part of the structure of the personality (e.g. someone who was raise d by a hostile and critical father may themselves feel persecuted by the introjection of th is object but also may \200\230become like \200\231 this object at other times). Freud \200\231s theory on depression suggests that it is caused by introjection of the aspects of others that make the depressed patient feel anger, leading to \200\230anger turned inward s \200\231. Projection Attributing one \200\231s own internal unacceptable ideas and impulses to an ext ernal target, such as another individual, and reacting accord- ingly to them (e.g. an angry child looks at his dog and accuses it of being angry). Projective identi \201 cation Behaving toward another in a manner that causes them to take on one \200\231s own internal unacceptable ideas and impulses. Not to be confused with pro jection. Whereas during projection an individual with a certain emotion might perceive some one else as feeling the same way, in projective identi \201 cation, the individual causes the other to feel that emotion (e.g. an angry child behaves in such a way that his mother b ecomes angry with him). Idealization and denigration Perceiving others as ideal in order to avoid con \202 icting feelings about them. Humans \201 nd it less anxiety-provoking to avoid ambivalence and gr ay areas within people. The converse of idealiza- tion is denigration where only bad is see n within others. Splitting Separating polarized and contradicting perceptions of self or oth- ers in order t o disregard awareness of both simultaneously (e.g. a patient believing that a doctor is \200\230the best doctor they have ever had \200\231 at one point, and \200\230the worst do ctor they have ever had \200\231 at another). This utilizes both idealization and denigrati on. Splitting can also happen intrasubjectively where patients split off parts of themselve s that they \201 nd unacceptable and project these parts onto another person. Acting out Literally acting out in ways that may reveal unconscious desires (e.g. a patient self-harming to express disgust at themselves). Regression Responding to stress by reverting to a level of functioning of a previous matura tional point (e.g. a teenager sucking their thumb around exam time). Neurotic defense mechanisms Repression Preventing unacceptable aspects of internal reality from com- ing to conscious attention. (A victim of childhood abuse may not have conscious a wareness of the abuse as an adult.) The associated emotional reaction may remain in the con scious mind but divorced from its accom- panying memory. 20_Semple_Chap20.indd 830 12/7/2012 4:32:54 PM defense MECHANISMS 831 Identi \201 cation Taking on the characteristics, feelings, and/or behaviors of someone el se as one \200\231s own. Differs from introjection in a similar manner to the way projectiv e identi \201 cation differs from projection. Whereas in introjection, one may perceive th emselves as being like someone else, in identi \201 cation one may actually feel the way s omeone else does, and become more like the other person. An extension of this is found in t he defense of identi \201 cation with the aggressor wherein those who have been victims of aggression become aggressive themselves as this feels to the person like a less vulnerable position (e.g. a young man who was physically abused may grow up to be violent to others r ather than remain in the vulnerable position of victim). Intellectualization Focusing on abstract concepts, logic, and other forms of intellectual r easoning to avoid facing painful emotions (e.g. a victim of a traumatic abuse experience ma y discuss the statistics of abuse instead of talking about the particular experience). Isolation of affect Separating an experience from the painful emotions asso- ciated with it (e.g. a victim describing a traumatic abuse experience with- out displaying any of the aff ect the experience has evoked). Rationalization Justifying feelings or behaviors with a more acceptable explanation, rather than examining the unacceptable explanation known to the unconscious mind (e.g. a mourner stating that the deceased person is \200\230in a better place now \200\231 in order to eas e feelings of guilt associated with the death). Reaction formation Externally expressing attitudes and behaviors which are the opposite of the unacceptable internal impulses (e.g. being extra polite to a person to avoid expressing anger towards them). Undoing and magical thinking The former is found when performing an action which has the ef fect of unconsciously \200\230canceling out \200\231 an unaccept- able internal impulse or previous experience. The action symbolizes the opposite outcome of the impulse or experien ce. Magical thinking is found when one attributes magical properties to thoughts or behavio rs, e.g. \200\230if I throw this piece of paper in the bin \201 ve times in a row then I \200\231ll pass my exams \200\231. Both these defenses are associated with OCD. Displacement Transferring the emotional response to a person to some- one else that in some way resembles the original but is not associated with as much con \202 ict or risk (e.g. a boy feeling anger towards a man who reminds him of his father, rather than towards his fa ther). Mature defense mechanisms Humor Finding aspects of an unpleasant experience funny or ironic in order to manage the experience without the associated painful emotions. Altruism Attending to the needs of others above one \200\231s own needs. Compensation Developing abilities in one area in response to a de \201 cit in another. Sublimation Expressing unacceptable internal impulses in socially accept- able ways. 20_Semple_Chap20.indd 831 12/7/2012 4:32:54 PM CHAPTER 20 Psychotherapy 832 Theory of psychosexual development Freud theorized that everyone is born with an instinctiv e sex drive called the libido, a primary source of tension if unsatis \201 ed. He develope d a the- ory that attempted to explain the development of the personality during infancy an d childhood. He visualized \201 ve phases, characterized by particu- lar satisfactions an d con \202 icts. Infants progressed from a state of primary narcissism, in which they \201 nd grati \201 cation in their own body processes, to \200\230object love \200\231, i n which they can more clearly separate themselves from other \200\230objects \200\231, or people. Inability to resolve the con \202 icts of a particular stage could lead to a lack of psychosexual development, while regression to an earlier state could result in the devel opment of neurotic symptoms (Table 20.1). Table 20.1 Phases of psychosexual develpoment Phase Source of pleasure Con \202 icts Oral phase Birth to 15 \200\22318 mths Love for breast of nursing mother vs. \200\230aggressive \200\231 urge to bite or spit. Suckling and investigation of objects by placing them in the mouth. Anal phase 15 \200\22318 to 30 \200\22336 mths Anal sensations, the production of feces and, later, the ability to withhold feces. Need to control sphincter enough to avoid shame of making a mess (related to pleasing autho rity and keeping orderly), but not so much that there is fecal retention. Phallic phase 30 \200\22348 mths to around the end of the \201 fth year Manipulation of the penis. Boys: Move through the Oedipal phase (Box 20.1). Girls: \200\230Penis envy \200\231 leading to feelings of inferiority (Note: this theory h as been rejected or modi \201 ed by many modern dynamic theorists) and pass through the El ectra complex (the inverse of the Oedipal complex). Oedipal phase 48 mths \200\2236 yrs Fantasies of sexual intercourse with opposite sex parent with a corresponding wish to kill the same sex parent. Boys: Love for mother vs. fear of castration by father, leading to \200\230castration anxi ety \200\231. Boy \200\231s unconscious desires were characterized by the \200\230Oedipus complex \200\231. Girls: Desire for a baby leads to attachment to father as someone who pot entially can give her one. Called the \200\230Electra complex \200\231. Latency phase 6 yrs until puberty Period of relative quiescence of sexual thoughts The anxieties from the previous phase are repressed. The sexual drive remains latent throug h this period. Genital phase Adult sexuality, beginning at puberty The sexual drive returns with greater strength than before. Improper resolution of previous phases may be manifest in symbolic ways. 20_Semple_Chap20.indd 832 12/7/2012 4:32:54 PM THEORY OF PSYCHOSEXUAL DEVELOPMENT 833 Box 20.1 The story of Oedipus (Sophocles 430 BC) King Laius of Thebes is told by the oracle at Delphi that his son will kill him and marry h is wife. When his wife Jocasta gives birth to a boy, Oedipus, he orders a slave to abandon the child on a mountain. The slave takes pity on the child and, instead of leaving him to d ie, gives him to a shepherd, who brings him to the King of Corinth who is childless. Oedipu s grows up thinking that Polibus, King of Corinth, is his father. As a youth, Oedipus visits the oracle at Delphi and is told that he will grow up to kill hi s father and marry his mother. At this, Oedipus vows never to return to Corinth and sets ou t for Thebes instead. On a narrow part of the road he meets an old man in a chariot who ang rily orders him aside and strikes him with a spear. Oedipus seizes the spear to defend hims elf and strikes the old man on the head, killing him. The man is Laius, King of Thebes, his real father. Approaching Thebes, Oedipus meets the Sphinx which is terrorizing the city. The monster is stopping all passers-by and challenging them with its riddle; those who fail to answer the riddle are devoured. Oedipus solves the riddle of the Sphinx and the monster jumps to its d eath. He enters the city as a hero. He is told that the king has been murdered and is offer ed the throne, together with the hand of Jocasta in marriage. Oedipus is a wise and successful king and Jocasta bears him two sons and two daughters. Man y years later Thebes is af \202 icted by a terrible plague. The people appeal to Oedipus t o save them and he sends his brother-in-law to the oracle at Delphi for advice. The oracle states that the plague will abate when the murderer of Laius is banished. Oedipus promises to bring the murderer to justice and forbids the people of Thebes from offering him any she lter. Oedipus asks the prophet Teiresias to help him discover the killer \200\231s identity. Teir esias tries to dissuade him from pursuing the matter but the king persists, eventually accu sing the prophet of being a fraud. Teiresias them angrily tells him that before nightfall h e will \201 nd himself \200\230both a brother and a father to his children \200\231. The king is bewildered and Jocasta tries to comfort him by telling him about the prophecy give n to Laius \200\224it was prophesied that he would be killed by his son, when in fact his s on had died as an infant and he had been killed by bandits \200\224hence prophe- cies could not be trusted. This story only increases Oedipus \200\231s worry and he suspects that he murdered Laius but does not yet realize that Laius was his father. A messenger arrives to inform him of the death of the King of Corinth. The messenger also r eveals that Oedipus was adopted. He begins to sus- pect that he is the son of Laius and con tinues to investigate, ignoring the pleas of Jocasta who has already realized the whole tru th. Eventually he \201 nds the shepherd who took him to the household of the King of Cori nth and the full truth is revealed. At this point he hears anguished cries com- ing from th e palace and rushes to his apartments. Oedipus breaks down the door of the royal bedchamber to \201 nd the queen, his wife and mother, has hanged herself. He seizes her dress pin a nd gouges out his eyes so as not to have to look at the atrocity he has unwittingly committ ed. He enters into exile, having failed to avoid the fate laid out for him. 20_Semple_Chap20.indd 833 12/7/2012 4:32:54 PM CHAPTER 20 Psychotherapy 834 Object relations theory In the mid-twentieth century Winnicott, Klein, Fairbairn, and other s devel- oped object relations theory which emphasized the importance of rela- tionships, r ather than drives such as sexuality and aggression, in affecting the mind. This theory desc ribes a model of infant psychological devel- opment, links abnormal early experiences to sy mptoms in later life, and uses this as a basis for interpretation in therapy. Object relati ons theory remains signi \201 cant in modern psychoanalytical practice. Essence Our \200\230sense of self \200\231 and our adult personality are developed as a re sult of the relationships we form in our lives. The earliest, and hence the most important, relationship is that between mother and child. Our early relationships form a template for future relationships, with abnormal early experiences being associated with psychological symptoms and abnormal relationships later in life. Theory The mind is viewed as blank at birth with the newborn unable to distinguish between \200\230myself \200\231 and \200\230everything else \200\231. Then the infant begins to v iew the external world as a series of (initially unconnected) \200\230objects \200\231. Th ese objects may be things (e.g. a toy, a blanket), people (e.g. mother, father), or parts o f people or things (e.g. the mother \200\231s breast, the mother \200\231s face). The infan t creates an internal representation of each object and has relationships with, and feeling s towards, the internal as well as the external objects. There are three primitive emotions (or \200\230affects \200\231) which an infant can dis- play towards each object \200\224attachment, frustration, and rejection. There is a tendenc y for a single affect to become associated with one object. Inevitably even a caring mother will create some feelings of frustration and rejection: mothers comfort their children and provide food and love, but also scold, punish and are sometimes simply unable to meet thei r child \200\231s needs. Consequently the child will view the mother as comprising a number of objects, some of which he views positively and some with hostility. The child will initially deal with this by keeping the \200\230good objects \200\231 (asso - ciated with attachment) separate from the \200\230bad objects \200\231 (those causing fr ustration and rejection) \200\224a phenomenon known as \200\230splitting \200\231. This is the initial primitive defense mechanism \200\224the \200\230paranoid \200\223schizoid pos ition \200\231. As the child develops, this defense becomes increasingly untenable and, in normal development the child will unify the good and bad maternal objects to a single \200 \230mother object \200\231 containing both good and bad \200\224the so-called \200\230depr essive position \200\231. The relationships we form later in life have a strong tendency to echo relationships from e arlier in our development. Interestingly, we can take on either role in these recapitulated relationships. Hence a child, one of whose parental relationships was with an aggressive/a busive father, can take on a \200\230victim \200\231 posture in some later relationships b ut may instead take on the role of the aggressor in others. In therapy The therapist \200\231s neutral stance provides an ideal environ- ment for the r ecapitulation of previous relationships. Most relationships 20_Semple_Chap20.indd 834 12/7/2012 4:32:54 PM OBJECT RELATIONS THEORY 835 are molded by both parties, but in therapy the therapist aims to allow the relationship mod el to be developed by the patient. The subsequent examination of the role and relationship forced onto the therapist (the transference) is a key part of therapy. Most therapies incor porating object relations theory help the patient resolve the pathological qualities of the transference through the experience of the real relationship between the therapist and the patient. Once these relationships are identi \201 ed they can begin to explore with the p atient how the relationship in the consulting room re \202 ects the patient \200\231s expe rience growing up as well as their current life-situations. 20_Semple_Chap20.indd 835 12/7/2012 4:32:54 PM CHAPTER 20 Psychotherapy 836 Psychoanalysis 1 Dynamic therapies, including psychoanalysis or psychodynamic psycho- thera py and group analysis are derived from the psychoanalytic principles and practice of Sigmun d Freud and those who have subsequently devel- oped his ideas. Most therapies which concept ualize an unconscious mind affecting our perceptions and actions can be considered part of the school of the dynamic psychotherapies. Rationale Traumatic experiences, particularly those in early life, give rise to psycho- log ical con \202 ict. The greater part of mental activity is unconscious and the conscious mi nd is protected from the experience of this con \202 ict by inbuilt defenses, designed to decrease \200\230unpleasure \200\231 and to diminish anxiety. These defenses are developme ntally appropriate but their continuation into adult life results in either psychological s ymptoms or in a diminished ability for personal growth and ful \201 lment. Con \202 ict c an be examined with regard to the anxiety itself, the defense, or the underlying wish or me mory. The individual \200\231s previous family and personal relationships will have sym- bo lic meaning and be charged with powerful emotions. Representations of these relationships w ill emerge during therapy and provide a route towards understanding and change. How illness is viewed Both mental illness and normal psychological development can be under - stood using psychoanalytic theories. In psychoanalysis overt symptoms are viewed as merel y the external expression of underlying psychic abnormal- ity. Symptoms continue, despite t he suffering they cause to the individual because of what Freud called primary gain. This i s the bene \201 t to the indi- vidual of not having unacceptable ideas in the conscious mi nd. While a typical descriptive assessment of a patient by a psychiatrist may categorize pa tients into groups using diagnostic criteria, a dynamic assessment of a patient uses psycho analytic theory to explore the unique layout of the individual patient \200\231s conscious and unconscious mind.