Over the last century there have been significant changes in understanding the mind and brain: both in psychiatric practice; and in psychotherapeutic practice. In psychodynamic thought the central change is a theoretical shift away from drive theory, with its intra-psychic focus, towards relational theory, with an intersubjective focus. The recognition of the role of relational trauma as a common basis for mental suffering confronts us with a communal responsibility to provide adequate therapeutic responses. In this talk some of the key points in the evolution of psychodynamic theory are highlighted, particularly seeking to identify points of practical application to current psychotherapeutic practice. In addition some of the research by the Westmead Psychotherapy Program is highlighted with respect to contributions to outcome, phenomenological, and process research.
Some findings point towards paradoxes in clinical presentations: for instance, people who present with self-harm often demonstrate marked “harm avoidance” as a temperamental characteristic; another study demonstrates a form of physiological dissociation in BPD that may account for some of its features. We have been one of few groups to demonstrate additional benefit in treatment when patients stay in therapy for a second year. A range of responses, including the Conversational Model at Westmead, and others such as Dialectical Behaviour Therapy and Metallisation Based Therapy have been applied to public sector services. This talk will look at the characteristics of these programs with a view to promoting a discussion on optimising psychotherapeutic treatment for clients presenting to public health settings.
Human beings develop in connected relationships, commencing with the touch, gaze, voice and affective tone of the proto-conversation and the sequencing of activities that tend to care, safety, comfort and play, extending to the therapeutic context where psychotherapy is the base for a healing relationship that fosters post-traumatic transformation, often mutual. Connectivity is constructed at every level of the individual and interpersonal systems: neurons fire and wire together, autonomic nervous systems are in conversation and the “soft wiring” and intrapersonal connections slowly unfold.
The Bare Essentials of the Conversational Model By Tony Korner Selves in Conversation Humans live in a language environment as much as they live in a physical one. Throughout life we are faced with decisions (or ‘motivated selections’) about whether to associate through language or to dissociate through non-communication. Each person’s life gets shaped by these decisions, many of which occur unconsciously under the influence of traumatic experience. Each self has the form of a story, an incomplete one. Dissociation, relating to trauma, is an important reason for this incompleteness.
The sense of self is inextricably connected to language, itself an intrinsically collective phenomenon with a life independent of individuals. If feeling provides an internal value system for self, then language can be thought of as providing an external value system, variably appropriated by individuals. Language consists of a network of differences; of relations within its own network; of shades of meaning. Its living qualities provide a gateway to “forms of life”. Communicative exchanges begin within a largely affective, indexical context: the proto-conversation.
To the layperson, narcissism is most often associated with arrogant, conceited, entitled behaviours which are captured by the term narcissistic grandiosity. This is consistent with common expressions of maladaptive behaviour such as self-enhancement and lack of empathy characterised by pathological narcissism. There is an emerging contemporary clinical model of pathological narcissism that combines grandiosity with clinically important regulatory impairment that leads to self, emotional and behavioural dysregulation in response to threats to self or failures of self-enhancement.
The emergence and development of The Conversational Model of Psychotherapy over the last 35 or so years arose out of a belief that models of psychotherapy ought to have a scientific basis. The key elements of the conversational model are dependent upon some key assumptions. These are that normal development is dependent upon our early infant and childhood relationships being able to meet our age appropriate needs. In time these relational experiences allow us to generate particularly integrated, reflective states of mind that we can call self and identify as health. Disruptions to that development (trauma) prevent the normal development of our cohesive, integrated and reflective sense of self. As a result we and others experience ourselves/us as living in a variety of fragmented, dissociative states that generate symptom clusters that are identified as pathology.