Where Perspectives Meet : Psychological Flexibility and Object Relations.

1. Where Perspectives Meet: Psychological Flexibility and Object Relations. Joseph D. Salande, M.S. David R. Perkins, Ph.D. Emily K. Sandoz, Ph.D.

2. What is Object Relations Theory? • Psychodynamic Theory • Strongly tied to Attachment Theory • Focuses on patterns of developmentally critical interactions between child and caregiver • The quality of these relations and their associated affective states become internalized, thus guiding future interpersonal and intrapersonal relations.

3. Modern Psychodynamic Psychotherapy • Most modern Psychodynamic Psychotherapies are based on Object Relations Theory. • Relational Patterns emerge through historical data as well as “here and now” behavior. • Psychodynamic Psychotherapy is centered on an experiential examination of the therapeutic relationship by both therapist and client. (Transference and Countertransference) • Analyzing Defensive Operations is an essential component. (diagnostically and therapeutically)

4. Transference & Countertransference • Transference refers to the client’s relational patterns that emerge between client and therapist. • Countertransference refers to the therapist's relational patterns that emerges between therapist and client. • Analyzing these relational patterns and their associated behaviors and affective states is important. • Correcting unhealthy intra-personal and interpersonal relational patterns is the central goal.

5. What is the Goal of Psychodynamic Psychotherapy? • The ultimate goal is to build up the inner resources of the client. • This is accomplished through strategies and tactics that are aimed at correcting key unhealthy relational patterns. • This coincides with the development of healthier defensive operations.

6. Are Psychodynamic treatment modalities empirically supported? There is a substantial body of research supporting the efficacy and effectiveness of Psychodynamic Psychotherapy. See below for meta-analytic studies. Abbass, A. A., Hancock, J. T., Henderson, J., & Kisely, S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews, Issue 4, Article No. CD004687. Abbass, A., Kisely, S., & Kroenke, K. (2009). Short-term psychodynamic psychotherapy for somatic disorders: Systematic review and metaanalysis of clinical trials. Psychotherapy and Psychosomatics, 78, 265– 274. Anderson, E. M., & Lambert, M. J. (1995). Short-term dynamically oriented psychotherapy: A review and meta-analysis. Clinical PsychologyReview, 15, 503–514. doi:10.1016/0272-7358(95)00027-M Leichsenring, F., & Leibing, E. (2003). The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: A meta-analysis. American Journal of Psychiatry, 160, 1223–1232. Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300, 1551–1565. Leichsenring, F., Rabung, S., & Leibing, E. (2004). The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: A meta-analysis. Archives of General Psychiatry, 61, 1208–1216. Messer, S. B., & Abbass, A. A. (in press). Evidence-based psychodynamic therapy with personality disorders. In J. Magnavita (Ed.), Evidence-based treatment of personality dysfunction: Principles, methods and processes. Washington, DC: American Psychological Association. de Maat, S., de Jonghe, F., Schoevers, R., & Dekker, J. (2009). The effectiveness of long-term psychoanalytic therapy: A systematic review of empirical studies. Harvard Review of Psychiatry, 17, 1–23.

7. What is Relational Frame Theory? • A well researched and supported theory of cognition and language acquisition. • Humans learn not just by direct experience, but also through derived stimulus relations. • “Humans learn to relate events mutually and in combination, without being limited by their form” (Fletcher & Hayes, p. 318) • The relational frames that we use to make sense out of the world can become maladaptive in the absence of psychological flexibility.

8. Acceptance and Commitment Therapy • Derived from RFT and Functional Contextualism • Strives to help client accept without judgment normally aversive internal events • The ultimate goal is increased psychological flexibility Six Processes of ACT Contact with present moment Defusion Acceptance Values Committed Action Self-As-Context

9. Psychological Flexibility According to Kashdan and Rotterburg (2010), psychological flexibility is comprised of several capacities… • adapts to fluctuating situational demands • reconfigures mental resources • shifts perspective • balances competing desires, needs, and life domains

10. Object Relational Health • Has an integrated set of internal representations of self and others. • Can hold competing conceptions of self and others • Can tolerate ambiguity • Can have a sense of authentic self/identity separate from others • Has the capacity to tolerate conflicting emotions • Copes effectively with the difficulties of life These capacities have an underlying implication of psychological flexibility.

11. Experiential Avoidance • “occurs when a person is unwilling to remain in contact with particular private experiences… and takes steps to alter the form or frequency of these events and the contexts that occasion them.” (Hayes, Wilson, Gifford, Follette, and Strosahl, 1996 pg. 1154) • “Freud Recognized the importance of avoidance in private experiences…”(pg.1154) • There are certainly some conceptual similarities between experiential avoidance and defensive operations.

12. Defensive Operations These are psychological maneuvers that defend the individual from aversive internal experiences by keeping these internal experiences buried in the unconscious. • Repression • Denial • Sublimation • Reaction Formation • Splitting • Regression • Identification • Projection • Projective Identification • Omnipotence & Devaluation • Displacement

13. Link between the ACT and Psychodynamic Psychotherapy. • Both take a more holistic approach to the classification of mental disorders, as well as treatment goals. • Both avoid directly attempting to change the form or frequency of an unpleasant internal event. • Both share an interest in understanding behavior, including internal events, in their fullest context.

14. Attributes of Effective Psychotherapy • The most potent factors in effective therapy involve the facilitation of a productive interpersonal relationship between client and therapist • From an Object Relations perspective, it makes perfect sense that the relational dynamics of the therapeutic experience are what matter most in effective therapy. • Many strategies and tactics shown helpful for facilitating successful therapy, regardless of therapeutic orientation, are psychodynamic in origin.

15. Implications for Clinicians • The experiential nature of ACT makes its tools more accessible to psychodynamically oriented clinicians. • Object Relations theory can help non-psychodynamically oriented clinicians put severely unhealthy behavior in an historical context. • The strategies and tactics of both ACT and Psychodynamic Psychotherapy are rich in factors shown to be related to effective psychotherapy. • ACT has important implications for acute symptom reduction that could be useful for psychodynamic therapists. • Psychodynamic/Object Relations Theory has important implications for long term outcome effect that could be useful to ACT therapists and other behavioral therapists.

16. References Hayes, S.C., Wilson, K.G., Gifford, E.V., Follete, V.M., Strosahl, K. (1996). Journal of Counseling and Clinical Psychology, Vol. 64 No. 6, 1152-1168 Fletcher, L., & Hayes, S. C. (2005). Relational Frame Theory, Acceptance and Commitment Therapy, and a functional analytic definition of mindfulness. Journal of Rational-Emotive and Cognitive-Behavioral Therapy, 23(4), 315-336. Godwin, A., (2010) Helping Adult Clients Grow Up. (Workbook) Cross Country Education. Greeberg, J.R. & Mitchell, S.A. (1983) Object Relations in Psychoanalytic Theory. Harvard University Press, Cambridge Mass. Kashdan, T., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30 (7), 865-878 Norcross, J.C. & Wampold, B.E. (2011) Evidence Based Therapy Relationships: Research Conclusions and Clinical Practices. Psychotherapy, Vol. 48, No. 1, 98-102 McWilliams, N. (1999) Psychoanalytic Case Formulation. The Guilford Press. New York, NY Wilson, K.G. & Dufrene, T. (2010) Things Might Go Terribly Horribly Wrong. New Harbinger Publications, Inc., CA.