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OF mental health care and mentally ill

Models of mental disorder-The psychodynamic model

The psychodynamic model is more accurately described as a style of human interaction and understanding that draws on a broad philosophy, which includes clinical, biological and evolutionary theory as well as religion and the arts. Psychodynamic practice may conjure an image of the psychoanalyst listening to their patient’s stream of consciousness as the patient lies on a couch at their side. This may occur but the psychodynamic model has many branches including some forms of family therapy, group therapies and art therapy. Common to all psychodynamic approaches, which delineates them from other psychotherapeutic perspectives (for example, behaviour therapy), is their primary focus on the ideas and feelings behind the words and actions that constitute human behaviour. Psychiatric disorders are not viewed as illnesses with disease-based aetiologies but as conflicts between different levels of mental functioning. Of critical importance here are the conscious and unconscious levels. Substantial amounts of mental activity that occur beyond our awareness are believed to determine much of our behaviour. Human development is important in this respect since a person’s early experiences can produce a particular gestalt or view of the person and their world, which they will take with them into adult life. This gestalt will include mental tricks and mechanisms to protect the person’s sense of self. Problems may arise if our gestalt, that we necessarily cling to, is at odds with the real circumstances we find ourselves in as adults. Let us take the simple example of a man whose childhood was coloured by restraint, control, uncertainty and occasional pleasure.

Then as an adult he works hard to please others, to demonstrate control and restraint in the expectation that doing for others will bring occasional pleasure. If this man was a priest then we may feel his gestalt fits his real circumstances. But suppose this man spent his life struggling to forge a career in marketing or merchant banking, or in the stock market to please his father? Though a simplistic example you may agree that conflict is likely to dominate this man’s experience. Conflict between his personal aspirations and the expectations of others. Conflict between his working alliances and the impossibility of any harmony in such a work environment. Conflict between his relative failings as a merchant banker and his father’s exacting standards. He may not be conscious of these specific conflicts but will nevertheless be affected by them as unconscious mental activity tries to reconcile the irreconcilable.

Quite literally, the psychodynamic therapist views psychological distress as the upshoots of unconscious thought. This simple principle is central to most if not all psychodynamic therapies. Different theories have been put forward within the psychodynamic tradition to explain different human experiences, but the founding father of the psychodynamic school was Sigmund Freud (1856–1939). Freud was a biological thinker interested primarily in an organism’s attraction to pleasure and repulsion from pain. Application of the pain/pleasure continuum to the human mind and its development led Freud to divide mental life into the id, ego and superego. The id represents our basic primitive instincts, present at birth, which tend toward the pursuit of pleasure or gratification. As we pursue gratification we become aware also of an external reality separate from ourselves and this realization necessitates the formulation of a self or ego.

Others in our world have helped shape the external reality in terms of laws, rules and social expectations. This realization leads to the development of the superego, which is more easily understood as our conscience. So we have needs (id), wishes (ego) and a conscience (superego) and, perhaps not surprisingly, psychological distress arises from the struggles that take place between them. Many of these struggles take place in the unconscious and Freudian analysts are concerned with healing the radical split between the conscious and unconscious, thereby creating a strong and healthy ego that is an accurate and acceptable self-image. Freud’s contemporaries and his followers have built subsequently upon his work to elaborate the psychodynamic school. Carl Jung (1875–1961) studied under Freud, who designated Jung his successor and crown prince. However, after less than ten years of collaboration they fell out over theoretical disagreements and never spoke to each other again!

While Freud had dedicated his work to the ego level of personal functioning, Jung was more inclined to examine transpersonal levels of human awareness. For Jung there were aspects of a person that appeared to transcend or go beyond the person, and this premise was incomprehensible to Freud, whose work had been confined to the realms of the ego or self. Jung had studied the great mythologies of the world, particularly their totems, ancient symbols, images and mythological motifs. What he discovered was that these images appeared with some regularity in the dreams and fantasies of modern Europeans, the majority of whom had never been exposed to these myths. His basic premise was that these primordial images, or archetypes as he called them, are common to all people. They do not belong to single individuals but are in fact transindividual or transcendent of the self. Jung called this deep layer of the psyche, in which the archetypes reside, the ‘collective unconscious’. Notice this is not individual consciousness but is something that resides deep within us all. According to Jung these archetypes live on, whether we are aware of them or not, and continue to move us deeply in creative but also destructive ways. As an example, Jungian therapists are interested in people’s key dreams and understanding the symbolism within them with recourse to ancient mythology.

Knowing what mythological images have meant over time to the human race as a whole enables people to understand what the images may mean in their experience of the collective unconscious. It follows that through such conscious integration people are no longer forcibly moved by unconscious archetypes. Therefore, though related to Freud’s ideas, Jung extended them beyond the organism to the cultural context within which the organism lives and used this context (or collective unconscious) to understand the psychic distress encountered by people. Melanie Klein (1882–1960) is another key psychodynamic theorist whose work focused on the first two to three months of a child’s life at a time when she believed the ego struggles to differentiate between itself and external reality. Unable to comprehend that good and bad can be present in the same object the infant assumes the paranoid position in which all things are either good or bad but never both. When able to comprehend that these qualities do exist in a single object (for example both the mother’s love and her chastisement) the infant experiences this new discovery and moves to the depressive position.

Therefore in Kleinian terms the experience and acceptance of depression is considered a maturational step necessary for personal growth. The influence of these early works on more contemporary psychodynamic therapies such as ‘humanistic therapy’, ‘drama therapy’, ‘art therapy’ and some forms of counselling is without doubt. Equally, the psychodynamic tradition has influenced mental health nursing, particularly through the works of Hildegard Peplau and Annie Altschul.

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