The psychodynamic frame of reference in occupational therapy is based on the theories of Freud. These theories have undergone continuous development and modification. After many changes, psychodynamic theory was considered as a theoretical base of the psychodynamic frame of reference in occupational therapy.
What is Freud’s psychodynamic theory?
The Psychodynamic theory is designed to help us understand Interpersonal relationships. The psychodynamic theory is based more on the unconscious forces (drives) than on conscious forces.
The two main aspects of psychodynamic theory considered in the psychodynamic frame of reference are –
1. Instinctual Drives (Forces)
2. Self as a mental Apparatus (Psychic Conflict)
Freud’s theory revolves around the satisfaction or gratification of the demands. He identified two primary instinctual impulses that demand gratification. First one is, Sexual drives and the second one is Aggressive Drives.
Sexual Drives – it is directly related to the pleasurable sensations, an individual gets after the positive output. Theses drives are considered to be the constructive element in motivation for most human activities.
Aggressive Drives– it reflects the need to relate with, adapt to, and master the external environment. These drives are considered to be the destructive element in response to frustration and conflict. Both the drives are used for the satisfaction of man’s basic needs- affectional and material.
To explain these drives and to maintain the balance between them, Freud developed the Structural Theory. Freud’s structural theory defined the mind as consisting of three structures, referred to as the id, the ego, and the superego.
The id is the unconscious part of the mind and considered as a source of the instinctual drives. We can say, id is the immature part of the mind which seeks pleasurable sensation all the time irrespective of the environment. Id is behind the every powerful desire, wishes, and fantasies.
The id is also considered as a part of primary process. The primary process is a mode of thinking dominated by affect-laden, wish-fulfilling fantasies derived from the drives. The id is considered as the earliest form of cognition.
The second structure of the mind is referred as the ego. The ego is the more mature part of the mind and discriminates between the internal (id) drives and constraints of external reality. Freud saw the ego as functioning as a mediator between external reality and the demands of the id.
The ego is based on the reality principle. It controls the drives by delaying, inhibiting, and restraining them in the interests of achieving their aims realistically. The ego tries to get maximum pleasurable sensation after balancing the id and environment.
The superego is the part of mental apparatus that represents the prescriptions and inhibitions of the outside world. The superego is that aspect of mental functioning that corresponds in a general way to what we ordinarily call “conscience (a person’s moral sense of right and wrong)”.
Ego has some primary function i.e. to control instinctual drives and to make a balance between Id and Superego.
According to Kaplan & Sudock, Ego has some other function too, they are –
#1. Object relations- Ego also helps to develop mutually satisfying relationship (object relationship) between the person and peer group or family members. Its depend on the establishment of trust on others. This helps to develop social interaction and relationship.
#2. Defensive function– this is one of the critical functions of ego, the ego of an individual uses defensive mechanism from being overwhelmed by anxiety come out from conflicting instinctual drives and superego demands. the Defensive mechanism is an unconscious attempt by an individual to prevent himself from anxiety. Though its unconscious reply to an input is observable in behavior.
Defensive mechanism is of different types –
Intellectualization, rationalization identification, introjections, projection, denial, repressive, reaction formation, isolation, undoing, displacement, and regression. Defensive mechanism and its types are a big topic of its own, you can read here for more information.
#3. Reality testing–
The ego also controls reality awareness. Reality testing is directly related to the internal perception and the external world. Many psychotic patients are unable to distinguish between the reality and their own world.
#4. Psychic Conflict–
The concept of psychic conflict is most simply defined as an internal struggle between the wish to express sexual or aggressive impulses (or both) on the one hand and the internal prohibition against expressing them on the other. This conflict may create anxiety. This is like a clash between the id & the superego and which is regulated by the Ego.
In the psychodynamic frame of reference, therapist searches for the main conflicting cause of anxiety and try to solve it.
Function –Dysfunction Continua (Areas of Concern)-
In this part of a frame of reference, occupational therapists more focus on the dysfunction derived from conflicts related to the expression on instinctual drives.
Dysfunction or anxiety may be seen when the person is not able to find the way to express and gratify drives to satisfy self in socially acceptable norms. Anxiety occurs due to unresolved unconscious conflicts. The Conflict areas must be assessed to develop the result oriented intervention plan.
Behavior indicative of function dysfunction (Assessment) –
The psychodynamic frame of reference guide occupational therapists to find out the conflicts under the behavior. Due to variations in the behavior, it is very crucial to observe the changes in behavior. The nature of the conflicts that produce the dysfunction (anxiety or symptoms) is identified through various techniques.
Projective activities generally used by occupational therapists– these activities help to understand the behavior of an individual. In these activities, the therapist identifies the symptoms through the exploration and interpretation of nonverbal symbols elicited by unstructured projective activities.
The occupational therapist uses different activities to assess the behavior. The individual is encouraged to use such unstructured media such as paints, clay and collage to facilitate the expression of internal feelings, experiences, fantasies, and personal unconscious symbols.
Postulates regarding change and intervention (Treatment)–
After getting the cause of conflict and anxiety. The therapist can plan out the right approach. First, it is important to catch the symptoms producing unconscious content and then bring it to consciousness. In the psychodynamic frame of reference, the goal would be to resolve the conflict and help the person to learn new, more satisfying behavior with conscious insight.
This line of treatment approach looks very easy and promising, but it is very challenging to bring patients insight.
Sometimes a patient may get aggressive and uncooperative. Initially, the occupational therapist should take the session in an environment which must be safe, supportive and empathic. It would be very difficult to assess and treat the psychotic patient in an unsupportive environment.
In psychodynamic frame of reference, the therapist works closely with the psychiatrist or psychologist in directing the patient to learn new behaviors through experiences in selected activities. Different activities are also selected to help determine the ability of the ego to integrate new information, to organize, and to problem solve.
Task groups – are generally used by the occupational therapist. It helps the person learn more self-satisfying and acceptable behaviors and communication skills in a supportive social setting.
Therapeutic use of self – in this approach, the therapist makes a therapeutic relationship with the patient. It includes understanding, neutrality or empathy, and caring of patient. The therapist accepts the patient as he or she is and tries to make a good rapport with the patient. This is the key skill to treat the psychotic patient.
Willard and Spackman’s Occupational Therapy