The foundation of psychodynamic theory is

IV.C. Symptom Substitution

Psychodynamic theories posit that phobias are expressions of unconscious conflicts. In Sigmund Freud's famous case of Little Hans, for example, the child's horse phobia was conceptualized as arising from an Oedipal conflict (i.e., unacceptable impulses consisting of libidinous longing for the mother and aggression toward the father). Such theories imply that exposure therapies simply treat the symptom (i.e., the phobia), without treating the underlying conflict, and that if one symptom is eliminated, then another will emerge in its place as a further expression of the unresolved conflict.

Research on exposure therapies for phobias has revealed no convincing evidence of symptom substitution. Once fears or phobias are eliminated by exposure therapy, the treatment-related gains tend to be maintained. Although new symptoms may sometimes later emerge (e.g., depressive symptoms), a more common pattern is that there is a generalization of treatment effects; once a patient's phobia has been reduced by exposure, the patient's mood may improve and he or she may become happier in general. This effect is most often seen when debilitating phobias have been eliminated, thereby enabling the person to enjoy a higher quality of life. Interestingly, in the treatment of phobias, even Freud recommended in vivo exposure as an important component of therapy.

Psychodynamic Theories

Psychodynamic theories focus on the psychological drives and forces within individuals that explain human behavior and personality. The theories originate from Sigmund Freud's psychoanalysis, which focused on the unconscious mind as the source of psychological distress and dysfunction. Psychoanalytic theory proposed the need for psychoanalytic therapy where the aim is to bring the unresolved issues, developed during childhood, or repressed trauma buried within the unconscious to the conscious mind in order for the client to begin to address these unresolved and underlying problems (Sharf, 2012).

Psychodynamic theories primarily deal with the unconscious motives that underpin an individual's personality and behavior. Childhood experiences are seen as critical in the development of the personality, behavior, and psychological thinking of an individual in later life, particularly psychological distress and dysfunction. Freud's drive theory, involving the three states of being (id, ego, and superego), are seen as important in understanding the role of the unconscious. The id is the unconscious that seeks self-gratification and fuels instincts, the superego is the conscious moral reasoning based on one's moral values and society's values, and the ego is the mediator between the id and the superego and seeks to make decisions based on the id's instincts and need for self-gratification and the superego's call for decisions based on moral values (Sharf, 2012).

Defense mechanisms, transference, and countertransference are terms often used when considering psychodynamic theories. Defense mechanisms are the tools used by the unconscious mind to prevent anxiety caused by unresolved issues and trauma. The mechanisms distort reality and are used to protect oneself by distancing from reality. Common defense mechanisms include denial, disassociation, regression, acting out, projection, or displacement (Sharf, 2012). Transference explains the act of a client unconsciously projecting thoughts, feeling and experiences of relationships, or interactions with previous significant figures onto a social worker. Countertransference is where the social worker's unconscious responds to signals received from the client and the social worker acts out a particular role (e.g., taking a parenting role) (Ruch et al., 2010).

Additional theorists have expanded on the ideas of the role of the unconscious and have shifted the attention in psychodynamic thought from one that focused on conflict, to one that focuses more on relationships. Jungian analysis and therapy explores the conscious and unconscious, but is equally interested in extroverted and introverted personality, archetypes, symbols, and dreams (Sharf, 2012). Adler's individual psychology, more commonly referred to as differential psychology, explores the ideas of inferiority, superiority, birth order, and individual differences (Sharf, 2012). Klein's object relations theory explores how relationships developed in infancy and childhood are embedded in the unconscious mind and form the focus of individuals' drives, views of themselves and others, influences their personality in adulthood, and dictates how they interact in interpersonal relationships (Sharf, 2012). Kohut's self-psychology expanded on object relations theory, aims to focus more on the self and the deficits within the self (Sharf, 2012).

Crisis theory is also classified as a psychodynamic theory as it explains how people cope with stressful situations and how they have the capability to grow, develop, and change based on the crisis. The theory holds that individuals reach a state of crisis when their existing coping skills are unable to deal with stressful or traumatic situations resulting in psychological and physiological distress (Caplan, 1964).

Psychodynamic theories are useful in social work assessments to explore a client's past experiences, hypothesize about how such experiences are contributing to the presenting problem and how to address the problem (or crisis). In this sense, psychodynamic theories influence social work assessments as well as the interventions employed, such as psychotherapy, crisis intervention, or transactional analysis. Acknowledgments and understandings of defense mechanisms can assist a social worker in explaining a client's behavior, interpersonal relationships, or reactions to information. Considering the role of transference and countertransference can assist the social worker in building the social work–client relationship (Ruch et al., 2010).

6.05.2.2 Formulation of Patients' Problems

Psychodynamic theory is too diverse to permit definitive formulations. Formulations identify central unconscious conflicts, mala-daptive defenses, unhelpful unconscious fantasies and expectations, deficits in personality development and the like. Formulation depends on the theoretical orientation of the psychodynamic clinician. In Chapter 14, Volume 1 of this work we have reviewed the range of currently popular orientations. Agreements, however, are hard to reach even when clinicians follow the same orientation (Horowitz, Rosenberg, Ureño, Kalehzan, & O'Halloran, 1989). Some standardized approaches have, however, been developed (Perry, Cooper, & Michels, 1987; Perry, Luborsky, Silberschatz, & Popp, 1989).

While there is no generally accepted schema for formulations, there are several key parameters that clinicians generally consider. These are: (i) the extent to which representations of relationships are mature, that is, involve three or more persons rather than just a two-person, self–other dimension (Karasu, 1990); (ii) the quality of psychic defenses, particularly the predominance of primitive defenses rather than more mature ones (Vaillant, 1992, and see below); (iii) the extent of whole, as opposed to part object relations (where individuals are represented as whole persons rather than just an aspect or a function of a person, e.g., feeding or nurturance, sexual gratification, a container for evacuation) (Kernberg, 1984).

Considerations such as these usually serve two functions. The first of these is to suggest the likely effectiveness of the type of treatment: short vs. long-term, intensive vs. nonintensive psychodynamic therapy. On the whole, patients seen as more severe on parameters such as the three suggested above are less likely to do well according to most studies of psychodynamic treatment (e.g., Wallerstein, 1986). The second function of formulations is to give an initial focus to the clinical work, which in the case of brief therapy may be the sole focus of the treatment. In long-term therapy these formulations tend to change, sometimes radically, on the basis of information emerging in the course of treatment. Winnicott (1965) referred to psychodynamic treatment as “an extended form of history taking.”

5.25.8.5 Emotional Communication

Traditional psychodynamic theory has been particularly prominent in the explanation of conversion disorder. According to this view, an unconscious intrapsychic conflict, wish, or need is “converted” into a somatic symptom, which presumably expresses symbolically some aspect of the conflict while at the same time protecting the person from conscious awareness (Engel, 1962). Critics of this perspective argue that the evidence is limited concerning the symbolic meaning of the symptom and its link to the unconscious.

More modern approaches assert that somatizing is a psychological defense whereby individuals experience and express emotional distress physically rather than acknowledge unpleasant affects, memories, or conflicts (Shapiro & Rosenfeld, 1987; Simon, 1991). Constructs such as alexithymia (Nemiah, 1977; Sifneos, 1973) and the defensive style of “repression” (Weinberger, Schwartz, & Davidson, 1979) have been proposed to explain the association between somatic symptoms and reduced emotional awareness and expression.

Alexithymia is characterized by difficulties in identifying and describing feelings, difficulty distinguishing between feelings and the bodily sensations of emotional arousal, limited imagination and fantasy life, and a concrete and reality-based cognitive style (Taylor, Baglay, Ryan, & Parker, 1990). Adult patients with somatization disorder have been found to have higher scores on a self-report measure of alexithymia compared to patients with other psychiatric disorders (Bagby, Taylor, & Parker, 1994; Taylor et al., 1990), although alexithymia has also been found to be associated with depression, neuroticism, and eating disorders (Bourke, Taylor, Parker, & Bagby, 1992; Cohen, Auld, & Brooker, 1994; Wise & Mann, 1994). More research needs to be conducted regarding the measurement and construct validity of alexithymia in adults, and its particular relation to somatoform disorders. There also has been almost no research on alexithymia in children.

Because young children have limited cognitive and linguistic abilities, it is not unusual to hear them express their emotional distress with physical symptoms. This might be particularly apparent in those families or cultures in which the expression of emotional distress is discouraged, whereas somatic complaints receive acceptance and attention (Escobar, Burnam, & Karno, 1987). Although there is a large developmental literature concerning the emergence of emotional competence in children (e.g., Saarni, 1990), little is known about the emotional development of children with somatoform disorders. Children who somatize might be especially likely to show delays or deviation in their emotional competence, particularly regarding emotional identification and expression; that is, they might be less competent at linking affects with situations, or expressing emotions in certain contexts, particularly those involving negative affect. Thus, although there has been considerable theoretical speculation about the role of affect expression and emotional competence in the development of somatization, the relevant empirical investigations have not yet been conducted.

Psychodynamic Theory

Another theoretical perspective on humor comes from psychodynamic theory, which began with Sigmund Freud’s interest in the meaning of adult joking behavior. Freud was particularly interested in the joking behavior of adults because he thought that jokes revealed much about adults’ unconscious emotions and motives by allowing them to express otherwise prohibited ideas (e.g., hostile and sexual) in a socially acceptable manner (it’s only a joke!). He reserved the word ‘humor’ for its use as a method of coping with difficult situations in which fear, sadness, or anger might be the likely emotions generated. For example, people living in oppressive regimes often use humor to help them cope, as do those with severe illnesses or others in dire life circumstances. Although Freud’s major focus was on adult joking, as part of his discussion of this topic he described three stages of joking development, beginning in early childhood. He called the first ‘play’ (ages 2–3 years), which involves repeating sounds or practicing unusual actions with objects to ‘rediscovering the familiar’. This stage has little cognitive purpose but it does indicate how children of toddler age juxtapose objects or actions in incongruous ways and find that funny because they know their actions with the objects are not correct. According to Freud, this stage is followed by a ‘jesting’ stage (ages 4–6 years), which Freud saw as the originating point for ‘nonsense’ humor. It is the first stage that requires an audience, but the child does not expect the adult to get particular meaning from the jest. By this age children know most adults expect reasonable behavior so jesting is an attempt to get their reaction to absurd behavior. Finally, true ‘joking’ behavior begins about age 6 or 7 years, and this mode gradually becomes more refined and extends through adulthood, resulting in expert use of the ‘joke façade’, which allows expression of tendacious feelings (i.e., hostility, sexual thought) to be expressed in public. An example of a child’s humor play in the first stage is the 2-year-old who first pushes his toy car along the floor but then begins having it do ‘tricks’ such as flipping over, going in circles, or driving up the wall, all of which behaviors are accompanied by laughter. At the jesting stage, adults may enter in and allow themselves to be ‘fooled’ by the child’s jest. For example, a child might call all the adults in the family ‘mommy’ and they might go along with the jest by responding as a mother would respond rather than telling the child he or she has made a mistake. Even at this early age, jesting may help children cope with anxieties about their abilities, especially in situations where they have just mastered some concept or experience but are still anxious about their knowledge or skill. For example, they may find it very funny to give their wrong name or say the wrong name of animals even though they know the correct names. The joking facade learned in the later age period starts out very crudely, perhaps with jokes about body functions, but as children grow older they become adept at using this form in various ways. For example, ‘insult’ jokes are very popular by middle childhood. This perspective on humor is useful in explaining how it can provide a vehicle for many types of emotional expression. Although not all adult humor has a hostile or sexual overtone, much of the humor used by professional comedians, in literature and other media, and in everyday social interactions, does have such connotations. The ability to laugh at such humor does not just depend on whether one understands the joke but on whether the meaning is derogatory of the group to which one belongs. Some interesting analyses of differences in humor understanding between males and females have been reported in a number of studies. These studies usually reported that men had a greater sense of humor (i.e., found cartoons funnier); however, the researchers often used humor-eliciting cartoons that were derogatory toward women. It is not surprising that the researchers reported women found the cartoons less funny than did men. Thus, the ability to understand the joke is not the only factor in humor appreciation; the nature of its message is also a factor.

Theoretical Reorientation

The evidence presented above collectively compels recognition that unconscious processing is real and requires formal acknowledgment. Bargh and Morsalla (2008) characterized contemporary cognitive psychology as conscious-centric. In this section I present reasons why, in addition to the massive empirical evidence presented above, psychological science requires an unconscious-centric orientation.

My first point is that an unconscious-centric orientation is able to explain much more than a conscious-centric orientation and therefore provides a much more general theoretical basis for psychological science. Contemporary cognitive psychology can explain only conscious cognitive phenomena but not consciousness itself. One argues from, not to, axioms. Explanations of how consciousness arises therefore lie outside the explanatory scope of conscious-centric psychology. Cognitive psychology cannot explain unconscious phenomena.

Presuming consciousness creates pragmatic problems. It makes it difficult to determine where consciousness processing ends and unconscious processing begins. This problem has impeded research into unconscious processing from a conscious-centric perspective for many years (Erdelyi, 1992). Conscious-centric psychologists therefore either deny that unconscious processing exists or claim that it lies outside the relevant explanatory sphere of their science. Conversely, the unconscious-centric position need only show how consciousness emerges. The network perspective introduced here does not assume consciousness and therefore is not precluded from explaining it. Consequently, the unconscious-centric perspective constitutes a more fundamental position. Replacing our current conscious centric orientation with an unconscious-centric one constitutes a major paradigm shift (cf., Kuhn, 1962, 1970, 1996, 2012).

Unconscious processing is the cornerstone of essentially all variants of Freudian psychodynamic theory. Chapter 9 reveals that the concept of unconscious processing was not original to Freud. In fact, this idea was introduced by the Greek physician Galen (c. A.D. 130–200) over two thousand years ago, and was vigorously discussed in Europe since the 1600s. Arthur Koestler’s introduction to Whyte’s (1978) The Unconscious Before Freud stated:

The general conception of unconscious mental process was conceivable (in post-Cartesian Europe) around 1700, topical around 1800, and fashionable around 1870–1880. It cannot be disputed that by 1870–1880 the general conception of the unconscious mind was a European commonplace and that many special applications of this general idea had been vigorously discussed for several decades.

Freud was writing about the unconscious in 1896. A scholar of his stature surely would have been aware of at least some of the extensive literature that he did not cite. Nevertheless, the evidence for unconscious processing is currently so extensive and robust that its existence seems finally to have been settled. Acceptance of unconscious processing by no means constitutes a full throated endorsement of psychoanalytic theory in its entirety. Rather, it recognizes that this part of psychodynamic theory is fully grounded in rigorous empirical research.

What does the psychodynamic theory focus on?

What are the 3 elements of psychodynamic theory?

When was psychodynamic theory founded?