Which one of psychologys Perspectives focuses on how behavior results from unconscious forces and internal conflicts?

Making the unconscious conscious

Psychoanalytic theory postulates a multitude of different change mechanisms, and a host of new ways of conceptualizing the change process continue to emerge as psychoanalytic theories themselves evolve and proliferate. At the most basic level, there is an understanding that change generally involves making the unconscious conscious, as expressed by Freud’s oft cited axiom: “Where id has been there shall ego be.” Although Freud’s understanding of the nature of the change process evolved over the course of his lifetime, central to his mature thinking was the idea that change involves first becoming aware of our instinctual impulses and unconscious wishes, and then learning to deal with them in a mature, rational, and reflective fashion. For Freud, a central premise was thus that we are driven by unconscious wishes that we are unaware of and this lack of awareness results in driven or self-defeating behavior. Freud believed we delude ourselves about reasons for our behaviors and this self-deception limits our choice. By becoming aware of our unconscious wishes and our defenses against them we increase the choices available to us. Thus, as we decrease the extent to which we are driven by unconscious factors we assume a greater degree of agency.

8 What is the relevance of psychoanalytic theory to understanding the experience of pain?

Psychoanalytic theory divides the psyche into three functions: the id—unconscious source of primitive sexual, dependency, and aggressive impulses; the superego—subconsciously interjects societal mores, setting standards to live by; and the ego—represents a sense of self and mediates between realities of the moment and psychic needs and conflicts. Psychoanalytic writings discuss how pain frustrates the satisfaction of dependency and sexual needs as well as appropriate dissipation of aggressive feelings. The blocked expression of these needs leads to inner turmoil. However, when sanctioned as a bona fide physical problem, pain allows for unconscious gratification of ambivalent dependency needs. Underlying anger may be expressed indirectly, in the form of passive-aggressive behaviors, whereby the patient holds family members and treating practitioner alike as hostages to endless complaints and demands for attention. The experiences of pain satisfy the superego's need to suffer and atone.

Psychodynamic theory

Psychoanalytic theories explain human behavior in terms of the interaction of various components of personality. Sigmund Freud was the founder of this school of thought. Freud drew on the physics of his day (thermodynamics) to coin the term psychodynamics. Based on the idea of converting heat into mechanical energy, he proposed psychic energy could be converted into behavior. Freud’s theory places central importance on dynamic, unconscious psychological conflicts.

Freud divided human personality into three significant components: the id, ego, and superego. The id acts according to the pleasure principle, demanding immediate gratification of its needs regardless of external environment; the ego then must emerge in order to realistically meet the wishes and demands of the id in accordance with the outside world, adhering to the reality principle. Finally, the superego (conscience) inculcates moral judgment and societal rules upon the ego, thus forcing the demands of the id to be met not only realistically but morally. The superego is the last function of the personality to develop and is the embodiment of parental/social ideals established during childhood. According to Freud, personality is based on the dynamic interactions of these three components.

13.1 Introduction

Psychoanalytic theory understands psychopathology within a developmental framework. Mental disorders like depression are seen as rooted in the individual past of a patient, that is, either as a residuum of early experience or as the expression of primitive modes of psychic functioning (Fonagy & Target, 2003). Within this framework, psychoanalytic concepts focus on the consequences of early interactions with significant others. These are thought to not only influence the development of psychic functioning but also build up the content of the individual self. The self as the subjectively experienced part of a psyche is seen as an integration of representations. These representations are memories of past interactions with others that shape how we experience ourselves and others in the present. Being part of the implicit memory, representations function as schemas that operate below consciousness. Whenever an individual takes part in a social interaction, representations serve as knowledge base and form expectations. Different terms have been used in psychoanalytic theory to name psychic representations: Kernberg (1984) focused on the dissociation of positive and negative self-object-affect triads in the borderline personality organization. Stern (2000) described the normal process of storing repeated infant–caregiver experiences in the episodic memory as “representations of interactions that have been generalized” (RIGs). In Stern’s view, RIGs create an unconscious expectation of the other (“mother will behave in a way as she has behaved before”), but new experiences with significant others can change RIGs. The older an individual becomes, the more interactions will contribute to the formation of RIGs, which in turn will lead to a decreased changeability of the representations. The unique contribution of Sandler and Sandler’s (1998) concept of inner self-object relations such as fantasies, thoughts, and the like that serve as pattern or template for any psychic activity, is how internalized representations form behavior. Internal objects push an individual unconsciously to repeat past interactions by forcing others in the roles of their internal objects and thus creating perception identity with the inner and the outer worlds.

In the present paper, the representational theory of inner working models (IWMs) of attachment will be applied because it is empirically well validated. After a brief introduction to attachment theory, this chapter focuses on the question of how depression can be understood from the perspective of attachment theory. Furthermore, I shall address if and how psychic representations in depressed patients can be changed in psychoanalytic psychotherapy from a recent psychotherapy study.

6 Are chronic pain syndromes a physical manifestation of a “masked depression”?

Traditional psychoanalytic theory postulated that pain could be a face-saving means of expressing underlying depressive symptomatology; hence, a masked depression. Individuals with such interpsychic dynamics had been labeled as “pain-prone personalities.” This has been a pervading construct, and it continues to have supporters.

However, more recent research and literature reviews point to depressive symptoms emerging as a consequence of the experience of chronic pain. The day-to-day burdens of chronic pain have been described as “major fateful events” that result in great psychological distress and significant, negative changes in lifestyle. Individuals with a biological predisposition for depression (the “scar hypothesis”) may be more vulnerable to the development of depressive symptoms as their condition worsens. In short, there is movement away from the idea of pain-prone personalities.

2.2 Psychoanalytic Theories

In psychoanalytic theory, as in Hall's theory of recapitulation, adolescence is seen as an inherent time of upheaval triggered by the inevitable changes of puberty. According to Freud, the hormonal changes of puberty upset the psychic balance that had been achieved during the prior psychosexual stage, latency. Because the hormonal changes of puberty are responsible for marked increases in sexual drive, the adolescent was thought to be temporarily thrown into a period of intrapsychic crisis, and old psychosexual conflicts, long buried in the unconscious, were revived. Freud and his followers believed that the main challenge of adolescence was to restore a psychic balance and resolve these conflicts. Working through these conflicts was necessary, Freud believed, in order for the individual to move into what he described as the final and most mature stage of psychosexual development—the genital stage. It was not until this stage of development that individuals were capable of mature sexual relationships with romantic partners.

Freud's daughter, Anna Freud (1958), extended much of her father's thinking to the study of development during the second decade of life. Her most important work, entitled Adolescence, continued the tradition begun by Hall in casting adolescence as a time of unavoidable conflict and both intrapsychic and familial turmoil. According to her view, the revivification of early psychosexual conflicts, caused by the hormonal changes of puberty, motivated the adolescent to sever emotional ties to his or her parents and turn to peers as objects of sexual desire and emotional affection. She described adolescence as a period of ‘normative disturbance’ and argued that the oppositionalism and defiance many parents encountered in their teenagers was not only normal, but desirable. Indeed, Anna Freud believed that adolescents needed to break away from their parents in order to develop into healthy and mature adults, a process known as detachment.

Over time, psychoanalytic theories of adolescence came to place less emphasis on the process of detachment or the motivating role of puberty, and began to emphasize the psychological capacities that developed as the adolescent negotiated a path toward independence and adult maturity. Psychoanalytic theorists of adolescence in the second half of the twentieth century turned their attention away from the analysis of drives and focused instead on the skills and capabilities individuals developed in order to resolve inner conflicts and establish and maintain mature relationships with others, especially others outside the family. The three most important writers in this neoanalytic tradition are Peter Blos (1979), whose theory of adolescent development emphasizes the growth of emotional autonomy from parents, a process called individuation; Harry Stack Sullivan (1953), whose view of adolescence revolves around the young person's growing need and capacity for intimate, sexual relationships with peers; and Erik Erikson (1968), who focused on the adolescent's quest for a sense of identity. By far the most important of the three theorists has been Erik Erikson.

Erikson's theory of the life cycle proposed eight stages in psychosocial development, each characterized by a specific ‘crisis’ that arose at that point in development because of the interplay between the internal forces of biology and the unique demands of society. According to him, adolescence revolves around the crisis of identity vs. identity diffusion. The challenge of adolescence is to resolve the identity crisis successfully and to emerge from the period with a coherent sense of who one is and where one is headed. In order to do this, the adolescent needs time to experiment with different roles and personalities. Erikson believed that adolescents needed a period of time during which they were free from excessive responsibility—a psychosocial moratorium, as he described it—in order to develop a strong sense of identity. This vision of adolescence as a period during which individuals ‘find themselves’ through exploration and experimentation has been a longstanding theme in portrayals of adolescence in literature, film, and television. Indeed, Erikson's notion of the identity crisis is one of the most enduring ideas in the social sciences.

Folk-psychological Accounts and Psychological Aspects

Following psychoanalytic theory, several researchers consider NDEs as a defence mechanism unfolding in a hopeless, life-threatening situation. Noyes and Kletti [110, 127] were influential with their suggestion that the experience during a NDE may reflect a form of depersonalization, whereby the endangered subject ‘separates’ from the body and the current events in order to be ‘dissociated’ from the unsupportable consequences of death and pain. Pfister [128] was perhaps the first to propose a psychoanalytic theory of NDEs. Following Heim's [42] accounts of NDEs in fall survivors, he suggested that ‘persons faced with potentially inescapable danger attempt to exclude this unpleasant reality from consciousness and “replace” it with pleasurable fantasies which protect them from being paralysed by emotional shock’ ([129], p. 613). By this process, it was then argued that subjects ‘split’ into an observing self and a body. The OBE component of many NDEs, in particular, has been seen as the prototypic experiential correlate of this detachment [1, 130]. However, this psychoanalytic account has been criticized on several grounds, mostly because of the lack of empirical evidence for it and the differences between the symptoms of dissociation in psychiatric populations and the reports of NDE subjects (for more details, see [131–132]), as well as many methodological and scientific concerns about psychoanalysis itself. Other psychological authors suggested that NDEs are the consequence of a human tendency to deny death [1, 130], the release of archetypical concepts of death [133], or the (symbolic or literal) regression to the experience of coming to life ([134–135]; but see [96]). These approaches of NDEs suffer from the same methodological and scientific concerns as psychoanalytical propositions.

More quantitative approaches have proposed to analyze psychological variables of people with NDEs, as estimated by interviews and questionnaire surveys. Yet, as with OBEs, no clear psychopathological features have been found [117, 131] and subjects with NDEs and without NDEs do not differ with respect to measures of intelligence, extraversion, neuroticism, or anxiety. Unfortunately, only a small number of subjects with NDEs have been studied in this systematic manner [136–137]. People with NDEs were also found to report more often so-called paranormal experiences prior to their NDE [83, 112], as well as other complex experiences such as OBEs, feelings of being united with the universe, feeling the presence of God and otherworldly entities, or having past-life memories [102]. Kohr [138] found similar tendencies in people with NDEs: they reported repeated OBEs and higher interest in dreams, past-lives, and meditation. This suggests that subjects with NDEs might differ from other subjects in being more open to unusual experiences (and also willing to report these) and being attentive to the so-called inner-states [129]. It might also be that this personality trait is linked to the larger concept of ‘magical thinking’, which has been shown to depend on right hemispheric activity and affinity to ‘paranormal’ thought [139]. People with NDEs as well as people with OBEs [11] also score higher than control subjects on absorption (a measure that refers to the tendency to immerse in imagination and internal states) and the related trait of fantasy proneness (a tendency to have vivid hallucinations, blurred distinction between reality and imagination, enhanced sensory experiences and heightened visual imagery) [117, 137]. The fact that this personality factor is shared among subjects with OBEs and NDEs again suggests common predisposing factors. On a related note, Ring [140] suggested that subjects with NDEs are more likely to have suffered abuse, stress, illness, and social problems during childhood than a control group (see also [132]). Measures of dissociation (and depersonalization) have also been associated with NDEs. Subjects with NDEs scored higher than controls, but were below the range of pathological conditions on this measure [141]. Britton and Bootzin [142] also found significantly higher scores in their group of NDE subjects on the Dissociative Experiences Scale (DES) than in their control group (again these scores were different between both groups, but within the normal range).

Psychodynamic Perspectives on Associative Theory

Classic psychoanalytic theory has a different view of associations and creativity. In essence, individual differences in comfort with primary process ideation accounts for the number and originality of associations. Primary process thinking is, according to Robert Holt, drive-laden oral, aggressive, and libidinal content and illogical thinking related to that content. It is a developmentally early, primitive system of thought not subject to logic and heavily affect-laden. Sigmund Freud thought that if individuals repressed ‘dangerous’ thoughts and wishes, then there would be a general intellectual restriction. In a primary process mode of thinking, ideas are easily interchangeable and attention is widely and flexibly distributed. There should be a broader search for associations for individuals comfortable with primary process ideation. There is strong empirical support or this hypothesis on various divergent thinking and association tasks, especially with male participants.

The psychodynamic perspective is consistent with Mednick's associative theory. It provides one explanation for why some individuals have such a steep associative hierarchy and others have a flat hierarchy. There is a looser connection among ideas for individuals who have easier access to primary process thinking. There is not such a strong bond among ideas and images so that more flexibility of thought and associations can occur.

For true creative production to occur, individuals must go back and forth between primary process thinking and more logical thinking (secondary process). This ability to access primary process in a controlled fashion is Ernst Kris's concept of “regression in the service of the ego.” Because production of a novel and useful product requires original associations and evaluation, both broad associations and critical thinking are necessary. The RAT actually measures both of these processes. As previously mentioned, the RAT is not a pure association task. It has been categorized as closer to an insight task because it requires broad associations but then has one correct answer that must be selected. In psychodynamic terms, one must access primary process thinking and then use critical evaluation to select the right response. Creative production is, at least, a two stage process. In an attempt to test this assumption, James Murray and Sandra Russ used the RAT with college students. They also gave them the Rorschach and scored it with Holt's well-validated primary process measure. The adaptive regression score on the Rorschach reflects both primary process content and the control of that content. This score significantly related to the RAT for the total sample and more strongly in the male participants (r = 0.42). This relationship was independent of SAT scores. In addition, adaptive regression related to the RAT more strongly than to measures of divergent thinking. We concluded from this study that a two-stage process accounted for the cognitive operations underlying adaptive regression and the RAT. The first stage was a generative stage while the second stage was an evaluative stage. In that sense, the RAT is a more global measure than are divergent thinking tests and is a more accurate reflection of the creative process.

Folk-Psychological Accounts and Psychological Aspects

Following psychoanalytic theory, several researchers consider NDEs as a defense mechanism unfolding in a hopeless, life-threatening situation. Noyes and Kletti (1976, 1977) were influential with their suggestion that the experience during a NDE may reflect a form of depersonalization, whereby the endangered subject “separates” from the body and the current events in order to be “separated” from the intolerable consequences of death and pain. Following Albert Heim’s (1892) report of NDEs in fall survivors, Oskar Pfister suggested that “persons faced with potentially inescapable danger attempt to exclude this unpleasant reality from consciousness and “replace” it with pleasurable fantasies which protect them from being paralyzed by emotional shock” (Pfister, 1930 quoted in Grosso, 1983, p. 613). By this process, it was then argued that subjects “split” into an observing self and a body. The OBE component of many NDEs, in particular, has been seen as the prototypic experiential correlate of this detachment (Menz, 1984; Ehrenwald, 1974) (for critique see Gabbard and Twemlow, 1984; Irwin, 1993). Psychological authors suggested that NDEs are the consequence of a human tendency to deny death (Menz, 1984; Ehrenwald, 1974), the release of archetypical concepts of death (Grosso, 1983), or the (symbolic or literal) regression to the experience of coming to life (Grof and Halifax, 1978; Sagan, 1980; but see Blackmore, 1993). These approaches of NDEs suffer from the same methodological and scientific concerns as psychoanalytical propositions.

More quantitative approaches have proposed to analyze psychological variables of people with NDEs, as estimated by interviews and questionnaire surveys. However, in comparison to OBEs, no clear psychopathological features have yet been found (Greyson, 2000; Gabbard and Twemlow, 1984). Also subjects with NDEs and without NDEs were not found to differ with respect to measures of intelligence, extraversion, neuroticism, or anxiety. Unfortunately, only a small number of subjects with NDEs have been studied in this systematic manner (Locke and Shontz, 1983; Twemlow and Gabbard, 1984). However, people with NDEs were found to report the so-called paranormal experiences prior to their NDE more often (Greyson, 2003; Groth-Marnat, 1994), as well as other complex experiences such as OBEs, feelings of being united with the universe, feeling the presence of God and other wordly entities, or having past-life memories (Osis and Harraldsson, 1977). It was also noted that people with NDEs tend to report repeated OBEs and higher interest in dreams, past-lives, and meditation (Kohr, 1983), suggesting that subjects with NDEs might differ from other subjects in being more open to unusual experiences (and also willing to report these) and being attentive to the so-called inner-states (Roberts and Owen, 1988). It might also be that this personality trait is linked to the larger concept of “magical thinking,” which has been shown to depend on right hemispheric activity and affinity to “paranormal” thought (Brugger and Taylor, 2003). People with NDEs as well as people with OBEs (Irwin, 1985) also score higher than control subjects on absorption (a measure that refers to the tendency to immerse in imagination and internal states) and the related trait of fantasy proneness (a tendency to have vivid hallucinations, blurred distinction between reality and imagination, enhanced sensory experiences, and heightened visual imagery) (Greyson, 2000; Twemlow and Gabbard, 1984). The fact that this personality factor is shared among subjects with OBEs and NDEs again suggests common predisposing factors. On a related note, Ring (1992) suggested that subjects with NDEs are more likely to have suffered abuse, stress, illness, and social problems during childhood than a control group (see also Irwin, 1993). Measures of dissociation (and depersonalization) have also been associated with NDEs. Subjects with NDEs scored higher than controls, but were below the range of pathological conditions on this measure (Greyson, 2000). Others also found significantly higher scores in a group of NDE subjects on the Dissociative Experiences Scale than in their control group (again these scores were different between both groups, but within the normal range) (Britton and Bootzin, 2004).

6.2 Implications for Choice of Symptom and Outcome

According to psychoanalytic theory the choice of symptom is determined by its symbolic meaning for the patient, and doubtless this is sometimes so. Usually, though, it is determined by cultural expectations and the subject's own experience of illness, in themselves or others. The nurse who develops hysterical blindness, for example, had severe conjunctivitis as a child, and the young man who loses the use of his legs had a grandfather who was housebound for years after a stroke.

Just as the development of hysterical symptoms is encouraged strongly by situations in which the balance of the advantages and disadvantages of sickness outweigh those of health, so recovery is encouraged by a reversal of that balance of advantage. This is why the symptom usually fades away if the situation that provoked its appearance resolves itself. If that situation persists, however, or if the inadequacies of the subject are paramount, the advantages and disadvantages of the chosen symptom become important. This is why disabling symptoms, like blindness or inability to stand or walk, have a comparatively good prognosis, whereas those which can be switched on or off as occasion demands, like fits or vomiting, or cause little disability, like tremors, are more intractable.