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The Psychodynamic Approach

We will start with one of the oldest traditions in psychotherapy: cathartic therapy, an example of the psycho­dynamic approach. Psychodynamic approaches attempt to analyze the dynamics (energies, movements, interactions between parts) in a person's psyche (overall personality and mind).

Psychodynamic therapies are distinguished by two common features:

1. Psychodynamic approaches emphasize personal history. Adelson and Doehrman (1980) write:

In comparison with almost all competing theories, the psycho­dynamic is distinctive in its emphasis on personal history.

It holds that in truly important mo­ments of one's life one is unwittingly held captive by the past. Whom we marry and how the marriage fares; the work we choose and how well we do it; whether we have children and when and how we raise them and feel about them; when we be­come ill and how we survive or fail to–all these and other vital events of the life course can be understood in depth only after we have a sufficient understanding of the personal past. (p.100)

What are two distinctive aspects of the psychodynamic approach?

2. Psychodynamic approaches emphasize unconscious motivations.

Psychodynamic therapists believe that people are affected by forces within themselves that the person does not understand. For example, a person may feel jealous of a rival without realizing it. Psychodynamic therapists also believe that people benefit from becoming aware of things previously hidden from themselves.

Later therapy approaches actually over­lapped with these "distinctive" features of psychodynamic therapies quite a bit. Rare is the psychotherapy that fails to delve into memories of earlier life.

Likewise, almost all therapists discuss hurts and grievances and hard-to-face worries, and almost all try to re-arrange the dynamics of emotions and thoughts. Perhaps it is most accurate to say early psychodynamic therapies pioneered those common features of therapies while dominating the first 70 years of psychotherapy.

The Cathartic Method

The idea that therapy should investigate a person's past to uncover hidden causes of current psychological problems is over 120 years old. The basic idea can be found in one of the first case histories of psychotherapy ever written, that of Anna O.

portrait of Anna O
Anna O. (Bertha Pappenheim)

Anna O. was a pseudonym (false name) for Bertha Pappenheim, a young woman who was treated in 1880 and 1881 by Dr. Joseph Breuer of Vienna, a friend and asso­ciate of Sigmund Freud. Freud never treated Anna O., but he was greatly influenced by Breuer's description of the case.

What was Anna O's real name? Did Freud ever treat her? Who was Breuer?

Breuer was a well respected physician in 1880s Vienna. He was a "doctor's doctor"–a physician other doctors sought when needing treatment. He was also "a fascinating and highly cultured personal­ity, a superb conversationalist, selfless and warm-hearted" (Sulloway, 1978).

In December, 1880, Dr. Breuer was called to the household of one of Vienna's richest families: the Pappen­heims. The father was dying of tuber­culosis. The 21-year-old daughter, Bertha, had been caring for her father until she developed an illness herself that required she be removed from his bedside. He died several months later.

Now Bertha had a terrible cough. Tuber­culosis was widespread in Vienna, and the first symptom was usually a cough, so this was alarming. However, when Breuer walked into Bertha's room and heard the cough, he knew it was not the cough of somebody with tuberculosis. Breuer suspected hysteria.

Today we think of a hysterical person as one who has lost self-control in a tense situation. In Breuer's day, the word was used for any physical symptom with a psychological cause, similar to the concept of a conversion disorder in Chapter 12 (Abnormal Psychology).

In 1880s Vienna, there was not just a tuberculosis epidemic, there was a hysteria epidemic. Doctors saw many cases of psychologically-caused medical symptoms.

How was the word hysteria used at the time? What is a modern name for the same thing?

Breuer knew that hypnosis sometimes helped hysterical patients get rid of their symptoms, so he decided to hypnotize Bertha. She was an excellent hypnotic subject.

In fact, Bertha practically put herself into a trance as soon as he suggested it. Under Breuer's care, Bertha began to improve. After three months she was able to walk across the room unaided.

However, progress was slow, and she was still troubled after a year. During a summer drought, she developed the inability to drink any water. The family had to keep her alive with orange juice, which was quite expensive.

Finally, during a hypnotic session with Breuer, there was a breakthrough. Bertha commented that she had a "tormenting thirst." Breuer asked, "What is tormenting you?" and Bertha replied, "That new governess!"

Breuer said the governess seemed perfectly nice to him. Bertha responded, "It's not her–it's her awful dog!"

Bertha went on to report a disturbing memory. About the time Bertha had developed her inability to drink, the Pappenheim family hired a new governess.

Bertha observed the governess's little dog lapping water out of one of the family's fine crystal glasses on the floor. This bothered Bertha a great deal, although at the time she suppressed the desire to speak out.

What breakthrough finally occurred, and how was it related to a memory?

When Bertha remembered this event under hypnosis, she shouted, "That disgusting dog! I wish I could throw something at it!"

Still under hypnosis, she grabbed a pillow and threw it across the room. Then she turned to Breuer and said, "Could I have a glass of water? I'm terribly thirsty."

Breuer brought her the water and she drank the entire glass and asked for another, waking from hypnosis with the glass at her lips. This was the first time she had accepted water to drink in over six weeks. After this incident, she no longer had problems drinking water.

Now Breuer had a clue: Perhaps Bertha's symptoms were related to specific, disturbing memories. He asked Bertha to recall incidents associated with her other hysterical symptoms.

Bertha worked backwards in time (sometimes with great difficulty remembering the incidents) until she eventually reached the earliest incident when the symptom occurred. The memories often involved her dying father. When she remembered the event that triggered the symptom, the symptom would grow suddenly worse and then it would vanish.

What was necessary, to make the symptoms vanish?

Breuer noted that he and Bertha had to discuss the incident in detail, to get any therapeutic effect. Bertha had to express deep emotion such as crying while remembering the event. If she simply remembered an event without emotion, her symptoms did not go away.

How did Bertha regain the use of her native language and her arm?

Another one of Bertha's symptoms was paralysis of her arm. Under hypnosis, she remembered dozens of occasions when her arm was unable to move.

Finally she worked back to her first memory of arm paralysis. She had been sitting by her father's bed, tired, perhaps dreaming. She hallucinated a black snake wiggling across the floor toward him.

She wanted to strike out against the snake, but her arm was asleep from being draped over the back of the chair. When she looked at her hand it seemed that her fingers had turned to little snakes, each with a tiny human skull in place of the fingernail.

She tried to cry out, but she could not. She tried to utter a prayer, but the only words that came to mind were the lyrics of a children's nursery rhyme in English.

This dream or hallucination marked the beginning of two symptoms: Bertha's inability to use her native German, and the paralysis of her arm. When she remembered the incident (with great emotion) the problems grew momentarily worse, then they went away.

What did Bertha call Dr. Breuer's therapy?

One by one, Dr. Breuer eliminated all of Bertha's hysterical symptoms. Bertha was much impressed. She spoke glowingly of her doctor and his "talking cure."

She also called it "chimney sweeping." When all her symptoms were gone, Breuer announced that she was cured, so he could stop coming to see her.

Evidently Bertha had fallen in love with Dr. Breuer. Late one night, several weeks after finishing his therapy with Bertha, Breuer received an urgent summons from the Pappenheim household.

Dr. Breuer found Bertha moaning on her bed, saying, "Here it comes...it's Dr. Breuer's baby!" She was not really delivering a baby; it was another hysterical symptom.

This was too much for Breuer. His own wife had just delivered a baby and was suffering from depression. Breuer cut off all contacts with Bertha, renounced the "talking cure," and left town on a second honeymoon with his wife.

What did Breuer and Freud suggest was the root cause of hysteria?

About five months after concluding his treatment of Bertha, Breuer told Freud about the case. Freud, then aged 26, was fascinated.

He looked at Breuer's notes and pressed Breuer to remember all the details. In 1893–over 10 years later–the two published a "preliminary communication" (brief article) in which they referred to Bertha as Anna O. and concluded that hysterics suffer mainly from reminiscences (memories).

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Reference:

Adelson, J. & Doehrman, M. J. (1980). The psychodynamic approach to adolescence. In J. Adelson (Ed.), Handbook of adolescent psychology New York: Wiley. (pp. 99-116).


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