QUESTION: You have a few moments to review your notes from your intake last week. Remember Susan, the 42 year-old woman who feels depressed? She was the one whose daughter is happily married and her son is away at college. She now feels alone and unfulfilled in a boring marriage and a lonely house. What is the psycho-social crisis this woman ought to be facing at her present age?
ANSWER: Stagnation v. generativity.
QUESTION: You wonder if getting married young and having her first child at 17 might have contributed to her present feelings of emptiness. What might Erikson think happened to your patient to cause her to feel depressed at this stage of her life?
ANSWER: Erikson had an “epigenetic” theory of passages through various stages of life. He believed that at each stage the ego faced an “identity crisis” as it attempted to resolve competing pulls between individual and social needs. He termed these “ego syntonic” and “ego dystonic.” Resolution involves achieving a synthesis between the two (in this case, “care”). Significantly for Susan, successful resolution of prior phases is necessary to confront the current stage. Her depression results from not having done so at this earlier stage of her life; her identity is incomplete.
QUESTION: In your imagination you hear Sigmund Freud say “this woman’s depression is a classic symptom caused by conflict between her id and superego.” What did Freud mean by that?
ANSWER: Freud distinguished between instincts and passions (the “id,” governed by “primary process thinking” and the “pleasure principle”); and the “superego” (governed by the “moralistic principle” and the “idealistic principle”). Their conflict is mediated by the “ego”, governed by “secondary process thinking” and the “reality principle.” The tension between id and superego results in “compromise formation” and the establishment of “ego defenses” such as sublimation, denial and repression. Susan’s depression most likely is the outcome of this process; she is working on processing and resolving the neurotic anxiety caused by the conflict.
QUESTION: At her next appointment you want to find out the severity of her depression. You know that sleep disorder is a key characteristic of major depression. You’re not surprised to her that she wakes up at 3:00 am most mornings feeling anxious and can’t get back to sleep. She recalls being chased in her dreams by a strange male. How did Freud refer to the “surface” content of a dream?
ANSWER: The “manifest” content.
QUESTION: How did Freud refer to the “underlying” content of the dream?
ANSWER: The “latent” content.
QUESTION: Jung would recognize the male figure in the dream as part of this woman’s “shadow.” What is the shadow?
ANSWER: The “shadow” is one of the basic archetypes. It represents the ego’s dark side- those aspects of personality that the ego wants to conceal from itself. It takes courage to confront the dark side in the process of individual growth and individuation.
QUESTION: You notice that your patient has a really “nice” persona. What is a “persona” according to Jung?
ANSWER: “Persona” is that part of the self one presents to the world. The “self” is one of the basic archetypes – in fact it is the central one. Jung was more concerned with “self” than with the Freudian ego.
QUESTION: If your patient has a “nice” persona, what might she be repressing?
ANSWER: She most likely is repressing her “shadow.”
QUESTION: Why would that be of interest to Jung?
ANSWER: Jung’s analytical psychology essentially is a psychology of opposites. Thus e.g. anima opposes animus, self opposes shadow, etc. From the standpoint of visual metaphor, he situated them in the form of a mandala, that is, a square within a circle within a square. For Jung personal growth is a process of individuation, that is, reconciling these opposing tensions.
QUESTION: It’s interesting, you muse, how often a young woman’s inner masculine seems to be connected to her shadow. That archetype seems to show up a lot in the dreams and dramas of life. You think about suggesting this to your patient and try to come up with a simple definition of the concept of archetype. What would that be?
ANSWER: An “archetype” is a primordial theme of human existence. It pertains to all people in all eras. It resides in the “collective unconscious,” which is the repository of human strivings, goals and emotions as experienced by each of us.
QUESTION: If she persists in avoiding awareness of these emotions she will be resisting the process of individuation. What did Jung mean by “individuation”?
ANSWER: Personal individuation is the central goal of Jung’s analytic psychology. It entails two basic attitudes, which are (1) introversion and (2) extroversion; and four basic functions, which are (1) thinking, (2) feeling, (3) sensing and (4) intuiting. By reconciling and expressing these at various stages of one’s life one successfully becomes a whole personality.
QUESTION: As you think about your client you wonder what Adler might have to say about her depression. What is a primary striving of human beings according to Adler?
ANSWER: Adler believed we start with an “inferiority complex.” We then strive for either “superiority” or “ego strength” depending on whether we concern ourselves with “social welfare,” which results in the latter. For Adler this is a process of choice, “style of life” and “final goals”.
QUESTION: If Adler were treating this woman, what are three things he might want to know about her?
ANSWER: (1) early family history and family systems, e.g. sibling position. (2) what are the goals she has set for herself as she constructs a personal narrative and schema or style of life by exercising choice. (3) in what ways did she feel inferior as a child and how did she address this by adopting social welfare and striving for ego strength v. superiority.
QUESTION: Your patient’s depression seems more situational than the depressive symptoms associated with what Adler called a “neurotic” personality. What are three characteristics Adler used to define a neurotic personality?
ANSWER: (1) unstable sense of self. (2) self-aggrandizement. (3) rigidity in outlook.
QUESTION: If your patient was neurotic and using the psychological defenses Adler called “neurotic safeguards,” what are three possible ones?
ANSWER: (1) excuses. (2) aggression. (3) withdrawal.
QUESTION: Speaking of neurotic safeguards, Karen Horney described something similar. What did she call them?
ANSWER: Neurotic impulses.
QUESTION: She also listed ten typical neurotic “needs”. Which two of these neurotic needs to you think might apply to your patient?
ANSWER: (1) need for acceptance and approval by others. (2) need to realize personal goals and ambitions.
QUESTION: Depression, you reflect, can be an internal distancing from chronic troubling emotions. What two troubling emotions would Karen Horney think your client might have struggled with as a child?
ANSWER: (1) basic hostility. (2) basic anxiety.
QUESTION: What causes these emotions?
ANSWER: They are caused by inadequate relationships at early phases of life with primary caregivers (“objects”) leading to an impoverished self-image and inability to achieve or realize the components of one’s ideal self.
QUESTION: According to Erikson, if your patient had successful attachment with her mother as an infant, at the age of two years what is the first psychosocial crisis she would have positively resolved?
ANSWER: Basic trust v. mistrust.
QUESTION: According to Erikson, what are the psychosocial crises that correspond to the second and third stages of life?
ANSWER: (1) early childhood: autonomy vs. shame/doubt; (2) play stage: initiative vs. guilt.
QUESTION: Heinz Kohut discussed the existence of two basic “narcissistic needs” in the developing infant. What are these two needs?
ANSWER: (1) need to model/incorporate idealized aspects of parent (self-object); (2) need to express personal grandeur and self-aggrandizement.
QUESTION: Kohut also discussed the importance of the developing child having positive “self-objects.” What is that?
ANSWER: “Self-object” is the concept of self that the parent has, which the parent makes available to the child, and the child then develops as her/his own through a process of mutual interaction.
QUESTION: If you consulted John Bowlby for insights on this patient, what would he mainly be interested in?
ANSWER: “Separation anxiety.” The child goes through three phases: (1) protest; (2) denial; and (3) detachment. The child adopts attachment styles, which are: (1) secure; (2) anxious-resistant; (3) anxious-avoidant; or (4) disorganized.
QUESTION: You’ve noticed that your patient has developed a positive transference to you. What is “transference”?
ANSWER: Transference is the process by which the patient substitutes the therapist for key figures in the patient’s childhood development, e.g. father/authority figure. In a broader sense it is the process of resonance or attuning by which two people achieve homeostasis with each other.
QUESTION: How might a positive transference benefit your patient in therapy?
ANSWER: Positive transference is of therapeutic benefit because it facilitates the excavation of repressed anxieties, neuroses and defenses. Other therapeutic techniques are free association, dream analysis and therapeutic interpretation. By identifying the therapist as the embodiment of e.g. a father figure, then the patient can come to terms with it in the present tense.
QUESTION: In spite of the positive transference, she still seems pretty defensive. Freud discussed a number of types of psychological defenses. Please list and define five:
ANSWER: (1) projection – grafting or implanting aspects of one’s own personality onto somebody else. (2) sublimation – substitution of a socially-acceptable object for id impulses. (3) introjection – assuming aspects of another’s personality and incorporating them into one’s own. (4) repression – unconscious subordination or redirection of undesirable id impulses into the unconscious. (5) denial – assertion of the exact opposite of what actually is the case as a defense against neurotic anxiety.
QUESTION: After interviewing your client further you discover her mother abandoned her at a very young age and that she actually has felt depressed for most of her life. You hypothesize that object relations theory might be useful to explain your patient’s difficulties. What are the key concepts of this theory?
ANSWER: Object relations theory hypothesizes that inadequacies in one’s relationships with primary care givers at an early phase of life influences one’s subsequent interpersonal relationships. This has several outcomes, which are:
(1) “splitting” – what happens when the child attempts to resolve the ambiguity presented by objects which are somewhat good and somewhat bad. The mother’s breast for example is a “good object” when it is available but becomes a “bad object” when it is not, even though it is one and the same thing.
(2) the “paranoid/schizoid position”, which is what happens to the child after undergoing the splitting process.
(3) the child also is vulnerable to the “depressive position,” which is the fear that the primary caregiver (e.g. the mother) will retaliate by making the object (the breast) unavailable.
(4) throughout the child experiences “phantasies,” which comprise its inner mental life.
QUESTION: How would these concepts apply to this patient?
ANSWER: In this case it appears Susan was unable to develop adequate object relationships with her mother, who abandoned her early in life. She was unable to replace the (absence of) her mother’s affection with satisfactory object relations with some other caregiver. This impasse and lack of resolution has precipitated her current (and on-going) depression.
QUESTION: What might be some of your therapeutic goals with this patient?
ANSWER: Therapeutic goals for her would include: (1) articulate early attachment relationships, if not with mother, then with other primary caregivers. (2) examine relationships with physical objects (e.g. teddy-bear) that may have substituted or served as surrogates for these relationships. (3) examine subsequent patterns of attachment and interpersonal relationships to discern underlying themes and motifs with a view towards relating them back to these early developmental conditions.
QUESTION: Your last patient of the day is a 26 year old male who wants you to help him with what he calls his “relationship phobia.” He tells you he never has been in a long-term relationship and at this point is afraid to get close to anyone. You have determined to apply Adler’s concept of individual psychology to see if it can explain your patient’s difficulties. What are the key concepts related to this perspective?
ANSWER: According to Adler each of us is born into a “family system” with associated roles and assumptions resulting from e.g. gender and sibling position. As a result we develop an “inferiority complex”. We have the capacity though to develop a “personal narrative” and a “style of life” (or “schema”) to explain who we are. We can choose a “final goal,” which is “that for the sake of which” we consciously direct our lives. We develop “social interest” which leads to an adaptive condition of “ego strength.” Failing that we are unable to resolve the inferiority complex and become captive in a maladaptive quest for “ego superiority.”
QUESTION: How might these concepts be applied to this case?
ANSWER: The patient’s anxiety results from lack of coping skills and personal resources due to never having resolved his initial inferiority complex. Only by doing so will he be able to form satisfactory relationships with others.
QUESTION: What could be some treatment goals for this patient?
ANSWER: (1) articulate early family structure. (2) examine its impact on early concept of self (inferiority complex). (3) discern personal goals. (4) identify choices that either have implemented or frustrated them. (5) explore self-construals (schema, style of life) that have affected the patient’s subsequent psychological development.