Psychodynamic Frame of Reference in OT: Guide & Examples

The psychodynamic frame of reference in occupational therapy is based on the theories of Freud. These theories have undergone continuous development and modification, including object relations theory. After many changes, psychodynamic theory became the theoretical base of the psychodynamic frame of reference in occupational therapy.

In OT, these ideas were brought into practice by pioneers such as Gail and Jay Fidler, who described occupational therapy as a communication process in psychiatry, and Hyman and Fern Azima, who developed one of the first projective assessments.

What is Freud’s psychodynamic theory?

Psychodynamic theory is designed to help us understand interpersonal relationships. It is based more on unconscious forces (drives) than on conscious ones.

Psychodynamic frame of reference

The two main aspects of psychodynamic theory used in the psychodynamic frame of reference are:

Instinctual drives (forces)
The self as a mental apparatus (psychic conflict)

Instinctual drives

Freud’s theory revolves around the satisfaction, or gratification, of demands. He identified two primary instinctual drives that demand gratification: sexual (libidinal) drives and aggressive drives.

Sexual drives are directly related to the pleasurable sensations a person gets after a positive outcome. These drives are considered the constructive element in motivation for most human activities.
Aggressive drives reflect the need to relate to, adapt to and master the external environment. They are considered the destructive element in response to frustration and conflict.

Both drives are used to satisfy a person’s basic needs, affectional and material.

Id, ego and superego

To explain these drives and the balance between them, Freud developed his structural theory. It defines the mind as having three structures: the id, the ego and the superego.

	Id	Ego	Superego
What it is	The unconscious source of instinctual drives; the immature part of the mind	The more mature part of the mind; the mediator	The inner voice of the rules and limits of the outside world
Works on	The pleasure principle and primary-process thinking: wish-fulfilling fantasy	The reality principle: delaying, inhibiting and restraining drives so their aims are met realistically	Morals: what we ordinarily call conscience
Example: hungry in a long meeting	"Grab the biscuits now!"	"There's a break in 10 minutes; I'll eat then."	"Eating while someone is speaking is rude."

Id: the unconscious part of the mind and the source of instinctual drives. It seeks pleasure all the time, regardless of the environment, and lies behind every powerful desire, wish and fantasy. The id belongs to the primary process, a mode of thinking dominated by emotion-laden, wish-fulfilling fantasies, and is considered the earliest form of cognition.
Ego: discriminates between internal drives and the constraints of external reality. Freud saw the ego as a mediator between external reality and the demands of the id. It tries to get maximum satisfaction after balancing the id and the environment.
Superego: the part of the mental apparatus that represents the prescriptions and prohibitions of the outside world. It corresponds in a general way to conscience, a person’s moral sense of right and wrong.

Id, ego and superego in the psychodynamic frame of reference

Functions of the ego

The ego’s primary function is to control instinctual drives and balance the id and superego. According to Kaplan and Sadock, the ego has other functions too.

1. Object relations

The ego helps develop mutually satisfying relationships (object relations) between the person and their peers and family. These depend on establishing trust in others, and they support social interaction and relationships.

2. Defensive functions

This is one of the ego’s critical functions. The ego uses defence mechanisms to stop the person being overwhelmed by anxiety arising from conflicting drives and superego demands. A defence mechanism is an unconscious attempt to protect oneself from anxiety. Although it’s unconscious, its effect can be seen in behaviour.

Common defence mechanisms, with everyday examples

Defence	What happens	Example
Denial	Refusing to accept a painful reality	After a heart attack, a man insists he's fine and skips rehab
Repression	Pushing distressing thoughts out of awareness	Having no memory of a frightening event
Projection	Seeing your own unacceptable feelings in others	"My colleague is always angry with me" when you are angry with them
Displacement	Redirecting feelings to a safer target	Shouting at your sibling after being criticised at work
Rationalisation	Giving a logical-sounding excuse	"I didn't want that job anyway" after not getting it
Intellectualisation	Focusing on facts to avoid feelings	Discussing statistics about a diagnosis instead of the fear
Reaction formation	Acting the opposite of what you feel	Being overly sweet to someone you strongly dislike
Regression	Returning to an earlier stage of behaviour	A child who was toilet trained starts wetting again when a new baby arrives
Undoing	Trying to 'cancel out' a thought or act	Buying an expensive gift after an argument
Identification and introjection	Taking on the qualities or values of another person	A teenager copying a coach's habits and beliefs
Isolation of affect	Separating a memory from its feelings	Describing a serious accident calmly, with no emotion

3. Reality testing

The ego also controls awareness of reality. Reality testing is directly related to internal perception and the external world. Many people experiencing psychosis are unable to distinguish between reality and their own inner world.

4. Psychic conflict

Psychic conflict is most simply defined as an internal struggle between the wish to express sexual or aggressive impulses, or both, and the internal prohibition against expressing them. This conflict may create anxiety. It is like a clash between the id and the superego, regulated by the ego. In the psychodynamic frame of reference, the therapist looks for the main conflict causing anxiety and tries to help resolve it.

Function–dysfunction continua (areas of concern)

In this part of the frame of reference, occupational therapists focus on dysfunction that comes from conflicts over the expression of instinctual drives.

Dysfunction or anxiety may appear when a person cannot find a way to express and satisfy their drives within socially acceptable norms. Anxiety arises from unresolved unconscious conflicts. The conflict areas must be assessed to develop a result-oriented intervention plan.

Evaluation: behaviours indicative of function and dysfunction

The psychodynamic frame of reference guides occupational therapists to find the conflicts underlying behaviour. Because behaviour varies, it is crucial to observe changes in it carefully. The nature of the conflicts that produce dysfunction (anxiety or symptoms) is identified through various techniques.

Projective activities are generally used by occupational therapists to understand a person’s behaviour. The therapist identifies symptoms by exploring and interpreting the nonverbal symbols produced in unstructured projective activities. The person is encouraged to use unstructured media such as paints, clay and collage to express internal feelings, experiences, fantasies and personal symbols.

Projective assessment	What the person does
Azima Battery	Free pencil drawings (including a person) and a clay model
B.H. Battery (Hemphill)	Mosaic tile and finger-painting tasks
Goodman Battery	A series of art tasks from structured to unstructured
Magazine Picture Collage	Chooses and arranges magazine pictures, then talks about them

Observations are explored with the person and interpreted within the whole team's assessment, never on their own.

Postulates regarding change and intervention

After identifying the cause of conflict and anxiety, the therapist can plan the right approach. First, it is important to recognise the unconscious content producing symptoms and bring it into consciousness. The goal is to resolve the conflict and help the person learn new, more satisfying behaviour with conscious insight.

This approach looks simple and promising, but building insight is very challenging. A person may become aggressive or uncooperative. Early sessions should take place in an environment that is safe, supportive and empathic; it would be very difficult to assess and treat someone in an unsupportive environment.

The therapist works closely with the psychiatrist or psychologist, helping the person learn new behaviours through experiences in selected activities. Activities are also chosen to show how well the ego can integrate new information, organise and solve problems.

The psychodynamic OT process

Safe relationship

Build trust through therapeutic use of self.
Expression

Projective or creative activity lets feelings come out.
Exploration

Talk about what was made and how it felt to make it.
Insight

Link the feelings to current conflicts and behaviour.
New behaviour

Practise more satisfying ways of acting in task groups and daily life.

Grading the structure of an activity

From open expression to structured doing

Most structured ↑

Task group with a shared goalStructured

Planning and cooking a group meal; roles and communication are practised.
Structured craftStructured

Following clear steps, e.g. a tile trivet or leather work.
Themed creative taskSemi-structured

A collage on 'my week' or 'what calms me'.
Free expressionUnstructured

Free painting, clay or drawing with no set topic.

Least structured

Unstructured media invite more expression; structured tasks give more safety and organisation. The OT chooses the level the person can manage.

Task groups

Task groups are commonly used by occupational therapists. They help people learn more self-satisfying and acceptable behaviour and communication skills in a supportive social setting. Fidler’s task-oriented groups use a shared activity, such as planning an outing or making a group mural, so that members can see and talk about how they work and relate together.

Therapeutic use of self

In this approach, the therapist builds a therapeutic relationship with the person, including understanding, neutrality or empathy, and care. The therapist accepts the person as they are and builds good rapport. This is a key skill in mental health OT, and especially important when working with someone experiencing psychosis.

Later developments: ego psychology and object relations theory

Later psychodynamic thinkers moved the focus from drives to relationships and the ego’s adaptive role:

Ego psychology (Anna Freud, Heinz Hartmann): the ego’s strengths and defences help people adapt to reality
Object relations theory (Melanie Klein, Donald Winnicott): early relationships with caregivers shape how we relate to people and the world. Winnicott’s idea of the transitional object (like a child’s comfort blanket) is often linked to how activities and objects can be meaningful.
In OT, Gail Fidler emphasised how people communicate feelings through activities and objects, and how the therapist’s relationship and the activity together can promote change.

Mosey’s analytical frame of reference (1970) is one of her “three frames of reference for mental health”, alongside the developmental and acquisitional frames.

Explorative vs supportive approaches

	Explorative	Supportive
Aim	Bring conflicts into awareness, gain insight	Strengthen the ego and healthy defences; cope better
Who it suits	People who are more stable and want deeper change	People who are acutely unwell or have long-term difficulties
Activities	Less structured, projective and expressive	Structured, familiar, success-oriented
Group type	Usually closed groups	Often open, structured groups

Psychodynamic vs other mental health frames

	Psychodynamic	Cognitive-behavioural	MOHO
Focus	Unconscious conflict, relationships, feelings expressed through activity	Thoughts, feelings and behaviour	Motivation, routines, roles, capacity
Tools	Projective activity, task groups, therapeutic use of self	Activity scheduling, graded exposure, problem solving	OPHI-II, MOHOST, graded occupation
Evidence	Mixed and limited in OT	Stronger for anxiety and depression	Growing, with many assessments

Read the cognitive-behavioural and MOHO guides.

Another case example

Neha, 34, has recurrent depression and finds it hard to talk about her feelings. In an expressive art group, she paints a small, dark house alone at the edge of the page. With the OT, she explores the painting and connects it to feeling isolated since moving cities. Over several sessions, through a task group planning a shared mural, she practises asking others for help, a new way of relating that she then tries with a colleague.

Test yourself: psychodynamic frame

0 / 3 correct

Which part of the mind works on the reality principle?

Show answer

B. The ego mediates between the id's drives and reality, using the reality principle.
Saying 'I didn't want that job anyway' after rejection is…

Show answer

B. Rationalisation gives a logical-sounding excuse to protect against painful feelings.
Which approach strengthens healthy defences rather than exploring conflict?

Show answer

B. Supportive approaches strengthen the ego and healthy defences.

Summary

The psychodynamic frame of reference sees behaviour as shaped by unconscious drives and conflicts between the id, ego and superego. Occupational therapists use projective activities to understand those conflicts, and activity, task groups and therapeutic use of self to help people gain insight and build more satisfying ways of living. Read more about OT in mental health, and other frames of reference:

References

Boyt Schell BA, Gillen G, eds. Willard and Spackman’s Occupational Therapy. Wolters Kluwer.
Bruce MA, Borg B. Psychosocial Frames of Reference: Core for Occupation-Based Practice. SLACK.
Fidler GS, Fidler JW. Occupational Therapy: A Communication Process in Psychiatry. Macmillan; 1963.
Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s Synopsis of Psychiatry. Wolters Kluwer.
Hemphill BJ, ed. The Evaluative Process in Psychiatric Occupational Therapy. SLACK.
Mosey AC. Three Frames of Reference for Mental Health. SLACK; 1970.
Winnicott DW. Playing and Reality. Tavistock; 1971.

Frequently asked questions

What is the psychodynamic frame of reference in OT?

It is a mental health frame of reference based on psychoanalytic theory. It assumes that unconscious conflicts create anxiety and affect behaviour, and uses activities, groups and the therapeutic relationship to help people express, understand and resolve those conflicts and learn more satisfying behaviour.

Who developed the psychodynamic frame of reference in occupational therapy?

It grew from Sigmund Freud's psychoanalytic theory and later object relations theory. In occupational therapy, Gail and Jay Fidler described occupational therapy as a communication process in psychiatry (1963), and Hyman and Fern Azima developed the Azima Battery, an early projective assessment.

What are projective activities in occupational therapy?

Projective activities are unstructured tasks, such as free painting, clay modelling, drawing or collage, in which a person 'projects' their feelings, experiences and personal symbols into what they make. The therapist explores what was made, and the process of making it, together with the person.

What is therapeutic use of self?

Therapeutic use of self is the therapist's planned use of their own personality, insight and responses as part of therapy. It includes empathy, acceptance, neutrality and building trust and rapport, so the person feels safe enough to engage.

Is the psychodynamic frame of reference still used today?

It is used less than in the past and its evidence base is mixed, but its ideas remain influential. Expressive activities, group work, attention to the therapeutic relationship and understanding of defence mechanisms are still part of many mental health OT services.

What is the object relations frame of reference?

Object relations is a development of psychodynamic theory that focuses on how early relationships with caregivers (the 'objects') shape how people relate to others and themselves. In OT, Gail Fidler and others used it to understand how people relate to activities, objects and people, and to use activity and relationships therapeutically.

What is the difference between psychodynamic and psychoanalytic?

Psychoanalytic usually refers to Freud's original theory and classical psychoanalysis. Psychodynamic is broader, including later developments such as ego psychology and object relations. OT's frame draws on these broader psychodynamic ideas and applies them through activity.

What are explorative and supportive approaches?

Explorative approaches aim to bring unconscious conflicts into awareness so they can be understood and resolved, often in closed groups for people who are more stable. Supportive approaches strengthen the ego and healthy defences, helping people cope, and suit people who are more unwell or have long-term difficulties.

Written by

Payal Mehta, OT

Payal Mehta is a practising occupational therapist and co-founder of Occupational Therapy OT. She writes on pediatrics, sensory integration, and mental-health practice.

All articles by Payal →

This article is for general education and is not a substitute for individualized assessment or treatment by a licensed occupational therapist. Always seek the guidance of a qualified professional for specific concerns.

Psychodynamic Frame of Reference in Occupational Therapy