Dynamic Psychotherapy Explained

Patricia Hughes, Daniel Riordan

• Publisher: CRC Press
• Year: 2017
• eBook ISBN: 9781315358628
• Topic: Medicina
• Subtopic: Teoria, pratica e riferimenti medici

This guide aims to help doctors and nurses solve the urgent problems they encounter on the ward or in the consulting room. This edition has been updated to include the latest in advanced disease symptom control and the text emphasizes clinical decisions in relation to each symptom. It now encompasses diseases such as AIDS, motor neurone disease and other life-threatening diseases. There are new sections on psychological problems, including breaking difficult ntes. Detailed drug information now includes a formulary. The work includes a chapter on emergencies, and discusses the management of severe pain and severe agitation. The appendices provide details on syringe drivers, drug doses, adverse effects and interactions, while management advice is set out in tables, providing easy access to practical information. Each section is accompanied by a comprehensive list of bibliographic references on the relevant subject.

1 A developmental model of the mind

Brain and mind • The mind–brain relationship • Born or made: the nature–nurture debate • The neurobiology of emotion • The effect of experience on the developing brain • The effect of severe deprivation and stress on the developing brain • The effect of experience on the mature brain • The nature of mental representations • Mental representations and relating to the world

Brain and mind

Main Points

• The brain contains the representation of experience which makes a person an individual.
• ‘Mind’ is the word used to designate the ‘higher functions of the brain’, namely thinking and feeling.
• From birth, human infants organise experience on the basis of similarities and differences. Experience is stored in the brain as neurally encoded mental representations of self and other with an associated affect.
• Mental representations have multiple associations with other thoughts and memories. Many associations are determined by social and cultural rules rather than by anatomical ones. These associations give meaning to a person’s thoughts, feelings and behaviour.
• This level of organisation constitutes psychological organisation.

The brain as a special organ

The brain is the only one of our organs that could not conceivably be given to another person. It is special because of the way in which it changes from birth to childhood to adult life. All of a person’s experience, all of the interactions of his body with the environment, are registered in his brain. And these experiences and the thoughts, memories and dreams which they stimulate make him the individual he is.

The functions of the brain

The functions of the brain include:

• sensory perception
• movement and motor control
• autonomic control
• the so-called ‘higher’ functions of thinking and feeling.

What do we mean by the mind?

The term ‘mind’ is used to designate the higher functions of the brain. The human brain or mind is different from the computer brain because it is linked to a body through which a person experiences the world. Mature functioning in the adult human brain requires that the brain has made representations of experience. These include the vast range of sensory, motor and interpersonal experiences which take place from infancy onwards.

Development of the mind

Developmental studies show that as a child acquires experiences he classifies them according to similarities and differences. These are across a range of variables, including physical characteristics, associated thoughts, emotional content and innumerable combinations of these. The representation of any particular experience in the brain is widespread – there are a huge number of synaptic connections, and one experience is not localised in one particular area. These representations of experience give meaning to a person’s thoughts and behaviours. This is a new level of organisation in the brain, the level of organisation according to meaning and association.

Thus we have anatomical organisation, physiological organisation and psychological organisation. For the most part, a person shares anatomical and physiological organisation with the species, but psychological organisation, although having much in common with that of other people, is also individual.

Psychological organisation

Mental representations have multiple associative links to other representations. As experience accumulates, the range of associations that determine how it is organised increases exponentially. Many of the associations are determined by social and cultural rules rather than primarily biological ones.

Thus a great deal of mental content is organised in terms of its meaning for the person. This is how we access it in psychotherapy – by understanding or attempting to understand the rules that the individual uses to represent self and the world. We assume that mental process and mental representations have a biological substrate – that is, that thoughts, for example, do not take place without activity at a synaptic level. Whether thoughts are the same thing as synaptic activity is the subject of much philosophical debate (Solms, 1997).

The mind–brain relationship

Main Points

• Change in the physical or chemical structure of the brain leads to mental change.
• Change in mental activity such as learning leads to change in brain structure.
• Much psychological organisation is complex and does not correspond with discrete anatomical areas.
• Evaluating mental representation will be a more useful way to access a person’s psychological working model of the world than exploring anatomical or physiological organisation.

The brain is the organ of the mind, and mental events must correspond to neurobiological activity in the brain. We assume that mental activities (for example, thought and feeling, memory, belief and desire) are accompanied by brain activity, which may be chemical, electrical and structural. This does not necessarily tell us that the one is caused by the other, although we know that the activities of brain and mind are related. This is important when critically evaluating papers or articles, especially in the popular press, where there is a common misunderstanding of the difference between correlation and cause.

Change in the physical or chemical structure of the brain leads to psychological change, and psychological experience leads to anatomical and physiological change. For example, experiments with drugs show that chemicals can change mental state, and diseases such as brain tumours, which affect brain structure, can cause changes in mental functioning. Research on immature (infant) non-human primates has shown that environmental modification leads to differences in both anatomical structure and chemical function in the brain (Kraemer, 1992; Teicher et al., 2002). Experiments on adult animals have demonstrated that new learning leads to changes in the structure of the brain (Kandell et al., 1995; Hensch, 2004). Recent research using neuroimaging has shown that some brain activity corresponding to mental activity can be observed in visual representations of the brain.

The anatomical structure of the brain can be identified either macroscopically by dissection of the brain, or using radiographic techniques which provide images of the living and active brain. We can directly link some mental activity (for example, visual perception) to anatomical areas of the brain. By performing assays of fluids and tissues in the brain and nervous system we can discover the physiological processes that operate within the brain, and we know, for example, that when we are emotionally aroused there will be a change in the level of biogenic amines in the central nervous system.

There are particular areas of the brain whose integrity is essential for certain aspects of psychological functioning. For example, if a person suffers severe injury to the prefrontal cortex, the capacity to regulate emotional arousal will be lost and the person will show emotional outbursts and disinhibited behaviour.

However, an understanding of anatomy and physiology cannot fully explain complex behaviours such as the ability to make friends, to work effectively or to feel self-confident. To make sense of these we need to investigate the psychological representations of self and the world which organise our behaviour. These mental representations will be the end result of interaction between genetic inheritance, social or environmental experience and a person’s current life situation.

Born or made: the nature–nurture debate

Main Points

• Gene expression depends to an extent on environmental influences.
• Early environmental events may have long-lasting effects on the immature organism.
• Behaviour, thoughts and feelings emerge as a result of the interaction of the genetic potential of the individual and the environment.
• Our knowledge of the genetic heritability of most psychological disorders is limited, so our ideas about heritability are rather speculative.
• A very few diseases are entirely genetically determined. Most have both an environmental and a genetic component. For many we do not know the relative contribution of genes and environment.
• Even disorders that are mainly determined by the impact of the environment must have a biological (although not necessarily a genetic) component.
• Changes brought about by social or psychotherapeutic intervention must ultimately affect the organism at the synaptic level.

Genes that programme the development of biological and psychological structures begin their effect before birth. The activation of the potential effect of a gene is called ‘expression of the gene.’ Some genes are inevitably expressed regardless of the environment in which the person is living. Others will be expressed to a greater or lesser extent depending on what happens to the organism (person), especially while it is immature. The principle that early events of development have long-lasting effects is one of the elemental precepts shared by all disciplines that study living organisms. The environment begins to exert its influence in utero and continues to be of importance after birth.

We inherit DNA from our biological parents. Behaviour, thoughts and feelings are not inherited. They are the outcome of the interaction of environment and our inherited genes. Another way of expressing this is to say that behaviour, thoughts and feelings emerge as a result of the impact of environmental factors on the developing neural circuitry.

Studies of identical twins reared apart reveal similarities in attitude and personality and indicate that human behaviour has a significant hereditary component. Further evidence is seen in the potential for selecting and breeding behavioural traits in laboratory and domestic animals. However, even identical twins reared together do not experience identical environmental conditions, and despite their similarities they also show distinct differences in personality.

A very few disorders are entirely genetically determined – for example, the degenerative brain disease, Huntington’s chorea. If one identical twin has the disease, the other will inevitably be affected. Other mental disorders are only partly genetically determined. Schizophrenia has a genetic component in its multifactorial aetiology. If one identical twin develops schizophrenia, his twin has a 50% or higher risk of developing the disease, compared with a 10% risk for non-identical twins. Schizophrenia is therefore an example of disease in which both genetic and environmental factors play a part.

For many years psychiatry was dominated by a debate about whether mental illness is caused by biological or psychosocial factors. This is an unhelpful way to conceptualise the causes of mental illness. A more useful question is ‘How do biological processes in the brain give rise to mental events, and how do social factors modify the biological structure of the brain?’. A balanced clinical approach will consider to what degree a mental disorder is determined by genetic factors, to what degree it is determined by developmental and environmental factors, and to what degree it is socially defined.

Even disorders that are heavily determined by social or developmental factors must have a biological aspect, because the activity of the brain will be modified. With regard to the way in which a psychosocial intervention works, whether it is psychotherapy or social manipulation of the environment, it must ultimately impinge on the individual by changing the connections between nerve cells. The absence of demonstrable structural change does not mean that change has not occurred. It is likely that, with increasing technological advances, assessment and evaluation of biological change will be possible at the synaptic level.

The neurobiology of emotion

Main Points

• Our external perceptions are mediated by the sensory modalities.
• Awareness of our internal state may be considered an internal perception.
• Arousal is a physiological response to perception which prepares the body for action.
• Thinking is a complex activity that involves many areas of the brain, but predominantly the associ...

Table of contents

• Cover Page
• Title Page
• Copyright
• Preface
• About the authors
• Acknowledgements
• Introduction
• 1 A developmental model of the mind
• 2 The psychodynamic in general psychiatry
• 3 What is psychotherapy?
• 4 Theory of psychodynamic psychotherapy
• 5 Doing it: the practice of psychodynamic psychotherapy
• 6 Conclusion
• Appendix 1 Finding a therapist
• Appendix 2 Who’s who in psychotherapy
• Appendix 3 Testing your knowledge
• Index