13. An introduction to the psychodynamic frame of reference
Margaret A. Daniel and Sheena E.E. Blair
Everyone in the helping professions should have a psychotherapeutic attitude, be familiar with the simpler forms of psychotherapeutic methods, and be aware of the scope and availability of more specialised forms of psychotherapy.
This is the underlying premise from which this chapter will proceed. Both authors of the chapter have retained a fascination with this approach to understanding people, organizations and society for over 30 years. So, regardless of whether careers have progressed within the direction of education, management, research or consultancy, an awareness of dynamic factors concerning anxiety, conflict, the effects on development of early life experience and the vibrancy of our inner lives has been retained. This approach celebrates the complexity of our emotional lives, attempts to understand and deal with corresponding feelings, and, in partnership with the person, couple, family, team or organization, seeks to find workable and helpful routes towards managing issues that negatively complicate human relations. In relation to our core professional values, we have not personally experienced a conceptual or professional tension between an interest in this approach and the practice of occupational therapy. Rather, the relationship between ‘doing’ and ‘feeling’ has always seemed intrinsically connected. Consider the times when a person is at a transitional point in their life and the frequent tendency to exclaim ‘What am I going to do!’ Our contention is that the dynamic relationship between feeling, thinking, doing and becoming needs to be continually reflected upon and understood. We also consider that an understanding of dynamic factors in human relations enables practitioners, managers and researchers to employ a unit of analysis which can facilitate change at a personal or a systems level.
• traces the evolution and current practice of psychodynamic thinking in occupational therapy
• analyses the relationship between occupational therapy and the psychodynamic approach
• considers the dynamics of doing and the occupational imperative
• explores group work within this approach
• explores the contribution to health and well-being.
From its inception, the profession of occupational therapy took its identity from the notion of occupation and the therapeutic belief that this contributed towards health and well-being (Wilcock 1998). The psychodynamic approach has contributed to our conceptual foundations alongside others now commonly described as ‘related-knowledge’ models of practice. Occupational therapy has striven to establish a corpus of knowledge specifically related to the understanding of occupational performance and how to comprehend the occupational nature of human beings. The historical development of this phenomenon has, according to some sources, been characterized by certain epistemological crises, particularly in the 1950s and 1970s. The concern was that related models did not focus on occupation clearly or specifically enough as the potential change mechanism for people who used the services of occupational therapy.
A renaissance of interest in occupation was stimulated by the development of discipline-specific models of practice such as the Model of Human Occupation (Kielhofner 2002). Related models of practice are multidisciplinary in nature. As such, this requires practitioners to employ a specific professional lens or ‘occupational filter’, a term that was coined by Forsyth and Mallinson (personal communication 2000). This ensures that the primary concern of occupational therapists is how — in the case of the psychodynamic approach — complicating feelings and issues in both internal and external worlds affected occupational lives.
This chapter intends to engage the reader in a wish to understand and evaluate critically this intriguing area within contemporary practice rather than offer a definitive account. Our contention is that, regardless of whether occupational therapists use a psychodynamic approach in their daily practice, a psychodynamic attitude as outlined by Bateman et al (2001) is an asset to their professional repertoire and enhances clinical reasoning and reflective practice.
Introduction to key ideas from psychodynamic practice
Any writer on the subject of psychodynamic practice would acknowledge the work of Sigmund Freud (1856–1939). He was a unique thinker and prolific writer whose ideas have continued to attract both admiration and derision. Two characteristic issues underpin Freudian thinking. They are the role of the unconscious and the impact of instincts. Freud used the contemporary cultural ideas of the late 19th century to evolve his concept of psychoanalysis. Just as a film projector transports an image on to a blank screen, Freud believed the inner working of the mind (psyche) could also influence our outer vision by expanding and creating additional layers to what is experienced, influenced by earlier past events. These representations, he believed, were contained in the unconscious and not fully in the control of the whole person (Gomez 1997). However, Freud’s biological training as a doctor and neurologist made him aware that his ideas would not be well received, as they were introspective and retrospective, influenced by personal insights that resulted in his continual reviewing and reshaping of his concepts. From the start, science and feelings were in conflict (Hughes 1999).
The central tenets of psychoanalysis are that symptoms are produced by conflicting unacceptable ideas about oneself or another. The emotions are translated into anxiety or psychic pain, and are defended against by actively locking them away in the unconscious (repression), enabling incompatible views to exist together. Defence mechanisms (Box 13.1) have a protective function that serve to deny, suppress or disown what we do not want to tolerate, and can be both helpful and harmful. Unacceptable feelings surface as motivational instincts, more commonly known as drives (Bateman et al 2001). They emerge from the unconscious as slips of the tongue, jokes, symptoms, or by the most direct route through our dreams. An example of this occurred when, after a talk about occupational therapy and psychodynamic work to undergraduate nurses, they seemed singularly unimpressed and the ensuing questions verged on confrontation. However, at the end of the allotted time, the tutor thanked the presenter profusely for coming, and she in turn tried to regain her composure and replied by thanking them for their ‘hostility’ instead of their ‘hospitality’! This inner experience won out over rational responses, everyone laughed and it served to illustrate a point about defence mechanisms, which everyone in the room recognized!
• The unconscious creates memory lapses that prevent painful, conflicting or difficult thoughts
• Complete avoidance of unpleasant reality that can induce anxiety
• Unacceptable feelings/impulses are attributed to others
• Exaggerated behaviour, which is the opposite of the actual feelings experienced
• Deliberately removing emotion from the issue by dealing only with logic
• Extreme attempts to justify behaviour or thoughts by giving numerous reasons
• Carrying on without avoiding the reality of the difficulty
• Behaving in ways characteristic of a much younger age
• Substituting something in place of a desired experience
• Seeking to excel in something to reduce feelings of failure in another area
• A primitive way in which reality is separated and distorted into polarized extremes, e.g. good/bad; right/wrong
Psychoanalysis is seen as a way of retrieving these censored memories, but it has been considerably modified since Freud’s time. This is an issue that is often overlooked in criticisms of this approach. As an intervention today, it offers a less intense and briefer form of therapy called psychodynamic psychotherapy, which seeks to give personal meaning to a person’s symptoms through understanding the relevance of the past to their present difficulties. It focuses on listening to the person’s story, with attention paid to how their early childhood experiences can be projected on to present relationships, inducing others to take up familiar roles from their past. Within the therapeutic relationship, the therapist can be on the receiving end of these feelings (transference), which can evoke the therapist’s feelings (counter-transference) and be used as a tool to deepen understanding (Bateman et al 2001).
Structuring the mind
Freud outlined three structural models of the mind, which neuroscience is beginning to map out on to the emerging contours in the psychoanalytic landscape, revealing, perhaps, what Freud was striving to attain (Balbernie 2001). His earliest theory believed that actions are affected by unconscious thoughts and feelings, creating symptom formation due to the dynamic tensions between conflicting conscious and unconscious thoughts and wishes. This became the basis of the first topographical theory, and was divided into three spatial levels: the conscious, preconscious and unconscious. The second structural model (Box 13.2) focused on drives in which the mind attempts to have its wishes satisfied. This new version was composed of the id, the ego and the superego. Berne (1961) subsequently adapted this concept to transactional analysis, using parent (superego), adult (ego) and child (id) to represent his psychic construction. Freud’s final model is the developmental theory, which suggested that early life proceeds in stages modifying adult activity.
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• This area is unconscious, and creates an overwhelming urge that takes over the individual with no thought for others. It is linked to the need to satisfy the drives of sex and aggression
• This more thoughtful and mainly conscious part of the mind can rationalize and consider others’ needs as well as those of the individual
• This area stems from the parental and authority influences that have been internalized and become the conscience that can be supportive or critical. It is part conscious and part unconscious
Influenced by Charles Darwin, Freud based his ideas on the continuation of the species, which he believed had to be sexually driven. For example, a baby’s pleasure is sought through body sensations, and moves from oral activity around the first year of life, through interest in anal activity in the second and third years, and finally to the genital phase around 3–5 years of age. These stages shape later life, and if the baby experiences trauma of either too little or too much stimulation at any of these stages it can hinder development and create problems later in life (Symington 1986). Erikson’s (1980) interest in child development emphasized the conscious and unconscious progression through eight life stages, resulting in a strengthened synthesis of thoughts and feelings. Freud’s longstanding friend and colleague, Sandor Ferenczi, continued to work with the environmental concept of trauma, realizing that, like children, his adult patients with neurosis longed to have what was passively beyond their grasp (Ferenczi 1949). For this to happen, trust had to be established, so that the shift into active engagement could take place. The later object–relations theorists, Winnicott, 1971, Bion, 1961 and Bowlby, 1988, took up Ferenczi’s belief in a form of maternal love (Ferenczi 1984) to counterbalance what had been lost. This was provided through attentive listening, sensitivity and piecing together of the trauma without overstepping boundaries. Object relations theory departed from the exclusive focus on the self by exploring the individual’s relationship with the environment and the urge to form relationships in the pursuit of well-being and the effective achievement of goals (Sutherland 1969). The intention of object relations is to attach meaning to relationships, artefacts or abstract concepts. Those were the ideas that caught the imagination of Fidler and Fidler (1963), whose communication process in occupational therapy revolved around activity, communication and the relationship with objects. Likewise, Mosey (1970) was interested in how symbolism and object relations were evident within clients’ engagement with activities. In Scotland, Batchelor (1970), while still an undergraduate, sought to differentiate occupational therapy from mainstream psychotherapy by the presence of objects that were ready-made, offered or created.
Donald Winnicott’s attention to the mother–infant relationship (Winnicott 1971) overlaps with the idea of object relations, and gives a sense of reciprocity that can lead to the first sense of unfolding identity. Winnicott, like Bion, saw the start of the infant’s inner emotional and intellectual life as being separate from, yet able to relate to, the outer world. He considered that, from the onset, the infant is part of a couple, and the intensity of this relationship gives the child the illusion that they exist as a single entity. Winnicott’s (1971)‘holding environment’ allows the infant the possibility of tolerating their surroundings, not unlike the therapeutic relationship. To assist an infant in coping with the gains and losses of separating, an object, such as a cloth or toy, is utilized to help make the alteration. Winnicott called this substitute used to replace the wanted object a ‘transitional object’, and it forms the first symbol of language. The absence of the object allows space for play, which, with ‘good enough mothering’, extends into adult life through culture and creative activity. In the occupational therapy literature, this idea has been embraced by Fidler and Velde (1999) in exploring the meanings that are inherent in activities, and more recently Blair (2000) has entertained the notion that certain occupations can be understood as protective during times of stressful transition. From a research base, the Swedish occupational therapist Eklund (2000) emphasizes the need for an integrative approach to gain a broader understanding of human activity performance. She uses the cultural work of Harry Sullivan and Donald Winnicott to argue that an object relations perspective is comparable with Kielhofner’s (1997) requirements for a conceptual model of occupational therapy practice.
What can be deduced from this brief overview of underpinning theories, all of which focus on the notion of successful change occurring in the mind of the individual, is the way that complex ideas have emerged and been adapted over the years. The therapeutic relationship, as Jenkins (1999) suggests, is seen as pivotal within occupational therapy. This frame of reference underpins specific work in child and family work, palliative care, substance abuse and certain areas of mental health. Apart from occupational therapy, the ideas have substantially influenced the practice of art therapy, mental health nursing, social work, education, organizational studies and, more recently, mental health promotion.
Over the last decade there have been a number of therapeutic developments (Box 13.3) that have striven to address the perceived imbalance or restrictions of the classical psychoanalytical therapy. These include a concern over the length of time that psychodynamic therapy takes, its cost and the lack of empirical research. Dialogic methods have become more widespread, and often depart from insight-oriented pursuits to those more linked to action, which is synonymous with an occupational therapy approach to adaptation and change.
Solution-oriented brief therapy
• The accent is on solutions rather than problems, and people are set problem-oriented goals that are mutually explored using techniques such as the miracle question, scaling questions and joint discussion of future possibilities
• A time-limited therapy that focuses on present-day problematic relationships, elevating mood level through active involvement with others. The focus is less on transference, and relies on a joint approach to improve well-being
Conversational model of psychodynamic–interpersonal therapy
• A collaborative and interpersonal approach incorporating psychodynamic aspects with humanistic and interpersonal components. It aims to achieve sensitive attunement to the feelings aroused in the session, and deepen understanding of how these emotions affect past and present relationships. It is a bridge between interpersonal psychotherapy and traditional psychotherapy
Cognitive behavioural therapy
• A pragmatic approach initially used for depression by altering unhelpful thinking processes evident in symptom formation. Recent trends are beginning to re-examine the role of the unconscious. The therapist takes an active informative role, encouraging the client to monitor patterns of automatic thinking on a daily basis. The focus is on recognizing unhelpful thoughts and feelings, so that new strategies can be incorporated to alter the patterning
Cognitive analytic therapy
• An integrative form of therapy, using past recollections and information acquired from the transference and counter-transference arising in the session. It also uses the cognitive choices a person makes by focusing on the effect this has on present relationships
The psychodynamic frame of reference has stood the test of time despite concerns from Barris et al (1983) that it had little to offer the contemporary practice of occupational therapy and that it had actively contributed to a crisis of identity within the profession. Perhaps success can be gauged by the extent to which Freud’s work has stimulated controversy, how it was one of the first theories to have a specific mode of practice, how it remains a crucial theme in the arts, and how it has acted as the springboard for subsequent therapies. Indeed, the original psychoanalytical ideas, which acted as both a theory and a form of treatment, became broadened into a diverse collection of neo-Freudian theories/models such as child psychotherapy, milieu therapy, family and marital therapy and group therapy, all of which retained a legacy to the ideas of Freud. This is not to deny that the approach is above legitimate criticism, as feminist writers have articulately documented (Appignanesi & Forrester 2000).
Psychodynamic thinking in all of those approaches and in current practice refers to the interchange between intrapersonal and interpersonal issues. This accentuates the process of therapy and the relationships that foster change, regardless of whether they are didactic or within a group setting.
The relationship between occupational therapy and the psychodynamic approach
It is interesting to reflect upon the way that psychodynamic ideas and ideas that acknowledged the value of occupation for mental health ran in parallel. At the turn of the 20th century, a new approach to the management of mental health was being developed across the Western world; it was called ‘mental hygiene’. The core belief was that mental ill health could be prevented by understanding the cause of mental illness. In doing this, people could achieve insight into their problems and surmount them by engaging in therapy. This was the crucial Freudian premise. Simultaneously, in the USA, a Swiss physician called Adolf Meyer was interested in transforming mental illness through occupation as a way to ‘normalize’, adapt and give meaning to peoples’ lives, both socially and environmentally (Winters 1951). There is every likelihood that the profession of occupational therapy owes some of its originating ideas to a psychobiological approach that attempted to synthesize neuroscience with psychoanalytical ideas.
Meyer spent time in the UK, and a network of like-minded clinicians was created within Scottish psychiatry. The eminent physician, David Henderson, actually delayed taking up a post in Glasgow to continue working for Meyer after his training in New York was complete. He subsequently returned to Gartnavel Royal Hospital in Glasgow in 1915, bringing with him Meyer’s clinical vision of occupation as a therapeutic resource. Meyer believed in a process of providing opportunities for people with mental health problems rather than the ubiquitous provision of medicines. His ideas of balance between activities and the use of meaningful daily occupations that reflected physical, psychological, social, emotional and spiritual components of our lives constituted a powerful blending of ideas. It was a vision that nurtured the origins of occupational therapy, and has been one which has sustained it through various ontological and epistemological crises.
In the 1950s, in the USA, an analytical approach was advocated by the work of Azima and Azima (1959), who outlined a theory of occupational therapy based on object relations theory, and it was in this article that the first mention of projective group therapy arose. This work substantially influenced that of Fidler and Fidler (1963), who wrote the seminal text for this approach alongside the work of Mosey (1970). The original text by the Fidlers remains the most innovative approach to analysis of activity in this frame of reference, despite changing contexts of practice and social change. Other authors in diverse parts of the world who have attempted to summarize work in the psychodynamic tradition all acknowledge the debt to those writers.
Within a Scottish context, the late 1960s and 1970s were a time when therapists were experimenting with explorative ways of using the creative arts range of activity primarily within a group context. This range of activities, which included art, music, poetry, pottery and drama, were used as ego-explorative activities, and were interspersed within treatment programmes with ego-supportive activities, which allowed insights and increased self-awareness to be put into practice. The choice of those activities was based upon a careful activity analysis of their properties, and a balance was always considered necessary between activities that sought to explore and those that were more supportive in nature. This was an integral part of an interdisciplinary psychodynamic approach to practice, which recognized that not all clients could find solace in purely verbal forms of psychotherapy. Batchelor (1970) was one of the first occupational therapists to publish on this topic, and was followed by Drost (1971), who discussed occupational therapy in groups; later, Affleck (1977) sought to introduce projective work within a unit for the treatment of alcohol problems. Blair (1974) worked primarily on the topic of occupational therapy and group work, while her colleague, Malcolm (1975), wrote about the versatility of painting within a psychodynamic approach.
Occupational therapists working within mental health across various countries became interested in projective techniques, which were defined by Remocker and Storch (1982, p.157) as ‘methods used to discover an individual’s attitudes, motivations, defensive manoeuvres and characteristic ways of responding through analysis of their responses to unstructured, ambiguous stimuli’. Their work is concentrated upon action techniques within a group setting, and is similar to the action-oriented methods used for organizational and human relations work. The work of Brown (1990), by contrast, focused upon drama, and used Moreno’s (1948) principles of ‘show me’ rather than ‘tell me’ within an analytical psychotherapy day unit in Glasgow. Amongst her ideas about this medium was a belief that occupational therapists were particularly suited to working with psychodrama because it was about the ‘psyche in action’.
Levens (1986) sought to outline the dynamics of activity, which in many ways echoed the earlier work of the Fidlers, and this served to sustain the interest of therapists in this area of practice into the 1980s. Robertson (1984) took a ‘broad-brush’ approach to the topic, and outlined the role of the occupational therapist within a psychotherapeutic setting, while Stockwell (1984) commenced the shift to the notion of creative therapies. In the 1990s, as Perez-Franco (1998) has highlighted, few articles appeared within the professional literature; nevertheless, there was a steady interest in specific areas such as group work within a unit for alcohol problems based upon Yalom’s (1970) work by Ogilvie et al (1995), a psychodynamic perspective on work with older people by Banks and Blair (1997) and the use of poetry for health and well-being (Jensen & Blair 1998). Findlay (1997) produced two texts, one on psychosocial occupational therapy and one on group work, which have acted as key texts since their creation.
The interest in creative therapies was developed by Stockwell (1984), nurtured by others such as Steward (1996) and culminated in an excellent text by Atkinson and Wells (2000), which they call a ‘psychodynamic approach within occupational therapy’. This is noteworthy for a number of reasons. Firstly, it is a clear exposition of theory and the links between psychodynamic practice and occupational therapy, and secondly it continually notes the relationship between ideas and creative therapy. The turn of the 21st century did not go unmarked by work in this area, and the links between a psychodynamic attitude and supervision within occupational therapy were outlined by Daniel and Blair (2002). Ingram (2001), along with Telford and Ainscough (1995), discussed the role of psychotherapeutic work within child and family psychiatry, and Nicholls, 2003 and Nicholls, 2008 has, through postgraduate study and further publication, sustained the profile of psychodynamic work in relation to occupational therapy. Nicholls is interested in the synthesis of work by Menzies Lyth, 1988 and Menzies Lyth, 1990 in relation to how occupational therapists tolerate the pain of the clients with whom they work. MacKenzie and Beecraft (2004) use an observational perspective to acknowledge the emotional impact of unconscious processes on staff working with older people. Jackson (2005) endorses their paper, seeing containment as the core to reflective practice, which Munro (2008) illustrates in her personal account of being seconded to a psychotherapy department, in which she emphasizes the need to have space to think. Extending the psychodynamic gaze further, Hyde’s (2006) organizational observations encourage staff to reflect on and develop an understanding of the unconscious to help them talk about their work.
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