What is Integrative Psychodynamic Psychotherapy?

Integrative Psychodynamic Psychotherapy is an innovative approach to psychotherapy, with predominantly psychodynamic orientation. Its theory is based upon integration of four psychoanalytic psychologies: Drive psychology (classical psychoanalytic theory), Ego psychology, Object relations psychology and Self psychology.
The emotion processing fundamental capabilities theses, extracted from the theories mentioned above, are the theses IPP is based on. The method of working with clients is likewise integrative, as it includes the techniques and skills originally established in variety of other psychotherapy approaches (such as: Psychoanalysis, Gestalt therapy, Transactional analysis, Bioenergetics, NLP, Focusing, Biofeedback and Neurofeedback, REBT etc. ) combined with the techniques and skills emanated from IPP, such as “IPP personality development protocols”, “Basic emotional competencies development protocols”, “Emotive accounting” and the “Mathematics of Psychology”… (Jovanović, 2013).

Nevertheless, IPP method is not an eclectic, but an integrative approach. The model of fundamental emotional competencies is the integration foundation for the variety of other psychotherapy approaches, techniques and skills. The core postulate of IPP method is “No tools, no work”, meaning that people cannot change if they do not develop or unblock their basic “life tools”. These tools are emotion processing basic capabilities, i.e. emotion processing psychological software (as emotions are information processing form). The bugs or viruses in these executive programs lead to unhealthy emotions, faulty perception and irrational interpretation of relations with the Self, the others and the world. IPP psychotherapist works with two levels: the level of content and the level of process. By listening the content of clients’ problems, talking to them about this content, their life events, their relations and love and work problems, IPP psychotherapist pays profound attention to the specific patterns and manners in which a client processes his experiences, as well as emotions triggered by these experiences.

Therapy techniques emanated from different approaches are used inwork with clients if they can contribute to development of a certain emotion processing fundamental capability. This represents the integration foundationof techniques from different approaches, whether they originate from psychodynamic, behaviour  or any other psychotherapeutic approach.

IPP method focuses on two main, composite capabilities: capability to work and capability to love. These two broad compoundlife handling capabilities are, like “Lego-bricks”, built of a certain number of smaller, much simpler bricks – basic emotional competencies:

1)                Neutralization and mentalization capabilities (which in IPP are labeled as regulator and articulator of the psyche)

2)                Object wholeness (the glue of the psyche)

3)                Object constancy (the stabilizer of the psyche)

4)                Ambivalence tolerance  (the orientation of the psyche)

5)                Frustration tolerance (the immunity of the psyche)

6)                Will (the engine of the psyche)

7)                Initiative (the actuator of the psyche)

If any of these “bricks” areomitted, the psyche remains defective (i.e. a person misses a part of the Self). Love and work capabilities are damaged.

If the neutralization capability is in an inchoate form, a person is guided by their urges and drives (“they lose their minds”). A person gets impulsive, irrational and unarticulated.

If a “glue of psyche” – object wholeness is damaged or not fully formed, maintaining the broader picture of reality, Self and object is impossible. The inner world of a person is split off and divided into a black and white clusters, the world of evil and good (a person is untogether, their perspective is either all positive or all negative, they either idealize or hate…).

Without the object constancy, i.e. the capability which ensures our emotional stability, people get unstable, codependent, needy and tend to cling onto others.

If frustration tolerance is underdeveloped, a person is not psychologically immune to inevitable life frustrations, love and work capabilities are, logically, undeveloped and immature, and such person can easily get extremely stressed out, crashed when under pressure.

If ambivalence tolerance is underdeveloped, a person is unable to make decisions and stick to them, is incapable to face antagonistic emotions towards someone of something (or their own Self) and equally incapable of resolution reaching, choosing one between two alternatives, is unable to make up their mind and be determined.

If will capability is underdeveloped, a person is lacking energy necessary to continuously support their desires and goals.

If initiative is not fully developed, a person is reactive, without the key for their psychological engine. A person with underdeveloped initiative needs someone else to get her move forward.

All the mentioned emotion processing capabilities are intertwined, mutually connected and in a reciprocal relationship. The following diagram depicts their mutual and reciprocal connection:

Fundamental emotionalcompetencies  are our life handling tools. Each of them is a  tool which can be used for healthy management of a certain type of anxiety. If underdeveloped or defective, each of fundamental emotion processing competences may be followed by a specific type of anxiety, which then is difficult to overcome. (Senić& Jovanović, 2011). Hence, the psychotherapy approach is defined by the anxiety type connected to the specific problem occurred in an emotional competence that should be mended, unblocked and/or developed. The following text will introduce us with the fundamental emotive tools and specific anxieties which could emerge from their faultiness.

Neutralization and mentalization  -overwhelming  anxiety

If neutralization capability is undeveloped (Hartmann, 1939, 1950, Kris, 1951) a person is enslaved by their urges and drives, unable to “get their head around”. A person gets impulsive, irrational and unarticulated. If mentalization capability (Fonagy, 2001, 2002, 2003) is underdeveloped or unformed, people could not mentally process their impulses and behaviours and are beside themselves as if something horrible is about to happen. People then tend to cork up their feelings as they are incapable of understanding them, as well as they are incapable of recognizing their own mental states and processes. When a person verbalizes their problem, they say something like: “ This is stronger than me”, “ I do not know why, but I cannot control myself as if something has overtook me” or  “Something came over me”…

Overwhelming anxiety is connected to “obsessiveness”, ideas of “craziness” and losing one’s mind”, “loss of control” – i. e. diffuse anxiety triggered by one’s own impulses and imagined forthcoming consequences. The common denominator of these anxieties is the flooding and overloading of the organism by too much energy that cannot be integrated and threatens to disorganize the personality.

Object wholeness underdevelopment leads to persecutory anxieties

If object wholeness (Klein, 1935, 1940) “the glue of psyche” is deficient, an ability to see a broader picture and experience the wholeness of the Self, the others, and the rest of the world is impaired. Hence, the experiences are split off (by the primitive defense mechanism known as splitting) and the world is divided into categories of mutually excluded either all good or all bad experiences  – “the world of good and evil”. The person is untogether. The basic mental operation in such state of mind is categorization (god or bad, hate or love… mutually excluded polar opposites of feelings, perception and resulting behaviors).

Persecutory anxieties represent the fears of annihilation and disintegration. These anxieties can be pervasive and verbalized as fears of falling apart, disintegrating, going crazy, being destroyed, becoming fragmented. The main defense mechanisms connected to this type of anxiety are the mechanisms of splitting and projection. This case of anxiety could be understood as manifestation of one’s own destructiveness – “I am rotten inside and my malevolence is going to destroy all the good things”.

Object constancy and separation anxiety

Object constancy (Hartmann, 1952) is known as a precondition for our psychological stability, hence, if this emotion processing capability is lacking, a person is unstable, codependent, needy, clinging onto others. A person does not possess a stable mental representation of the object and the Self, and is also incapable for Self-regulation.The “need – fear dilemma” (Akhtar, 1987, 1990, 1994., Burngam, 1969)is pronounced. This dilemma leads to symbiotic desires and, at the same time, to the fear of suffocating, loosing oneself and personality boundaries and one’s Ego in a relationship. Different types of anxieties can be met and dominant in each phase of the object constancy development (Mahler, 1963, 1968, 1974).

In symbiotic phase dominant anxieties are the ones connected to helplessness, universal loneliness, followed by the ideas that the world is empty, devoided and  without „objects”. (Akhtar, 1990b., Blum, 1981)

Sub-phase of self and object differentiation is connected to „suffocating anxiety”, followed by the ideas of loosing Self in a relationship“ (Akhtar, 1987; Fairbairn, 1952; Guntrip, 1969)

Reapproaching sub-phase (Akhtar, 1990; Gunderson, 1985; Melges& Swartz, 1989) is connected to anxieties appeared in regard to loss of support. The main idea is that one “cannot go back”, “change one’s mind” and, as a result, the separation guilt arises from this idea.

The separation sub-phase (Winnicott, 1965; Mahler, 1974; Akhtar, 1992) is followed by separation anxieties, which are connected to loss of objects, inabillity to be alone, fear of being alone and on one’s own.

Frustration intolerance  produces anxieties connected to failure to tolerate counterreaction (which often is verbalized as „I cannot stand this”)

Without well developed frustration tolerance, a person is not immune to inevitable life frustrations. Hence, work and love capabilities are underdeveloped, and a person cannot stand to work and or to relate to others under pressure.

“Achilles heel” is a specific frustration one could not tolerate, followed by anxieties, which often are verbalized as “This must not happen” or “What if… this and this happens…?”

Specific frustration intolerances i.e. anxieties connected to failure of tolerating counterreaction could be categorised by multiple criteria. If the criterion is classical psychoanalytic drive theory (Freud, 1905), the frustrations are organized around psychosexual developmental stages as  a) oral frustrations (frustrated receptive and protection needs) b) anal frustrations (frustrations regarding autonomy, retentiveness and “ownership”) c) phallic frustrations ( exhibitionistic frustrations, rivalry frustrations… ).

Narcissistic needs frustration intolerances (Kohut, 1971.; Wolf,  1980) are recognized as narcissistic hypersensitivity, especially toward narcissistic injuries (the grandiose Self) and  injuries toward idealized object (idealized parental imago). Anxieties from this realm are known as narcissistic anxieties and are related to feelings of shame and states of worthlessness.

Ambivalence tolerance – anxieties connected to decision making and fear of making mistakes (Hartman &Zimberoff,  2003).

Withoutthe capability to tolerate ambivalence, a person is indecisive, incapable to face antagonistic emotions towards someone of something (or their own Self) and equally incapable of decision making, choosing one between two alternatives, is unable to make up their mind and be determined. Mature decision making encounters cost and benefit analysis and genuine dealing with all the antagonistic emotions that one experiences toward the object (Self or the world).

If ambivalence tolerance is underdeveloped, we are met with anxieties related to decision making, loss of control, ambivalent emotions toward the object and fears of possible mistakes.

We are also met with anxieties regarding responsibility taking.
Will capability – anxieties related to self-support, endurance, stamina…(May, R., 1966; Rank, O. 1972; Assagioli, R. 1973)

Without the mature will, a person is lacking energy necessary to continuously support  their desires and goals. A person could also be manipulative and may tend to intrusively force others to obey to their will.

Anxieties related to lack of self-confidence are often noticed through doubtful questions, such as “ can I rely onto my will, self-discipline and endurance…?”

Anxieties related to loss of freedom, autonomy, anxieties about being used, followed by the idea that someone is going to enslave a person, to use them or to subordinate them, are connected to analogous behaviours: a person with underdeveloped will get exposed to be used, so they can oppose to the control.

Initiative – anxieties related to rivalry, showing off “castration anxiety” (Erikson, 1959; Ikonen, 1988.)

Without the maturity of initiative a person is reactive, without the key for their psychological engine. A person with underdeveloped initiative needs someone else to get her move forward. They are afraid to independently commit themselves to a goal and stand for it.

Castration anxiety manifests as a fear of humiliation, degradation, punishment if a person shows off, is exibitionistic or if they want something they believe they should not desire, something they are not entitled to…

Rivalry anxiety is connected to fears of being defeated, impotent (which symbolizes “smaller penis syndrome”). In sum, it represents anxiety about the possibility that the rival is going to win and a person is going to be humiliated.

In Self Psychology, we are also introduced with anxieties regarding narcissistic injuries (Kohut, 1977)

It is hard to live, love and work without fully developedemotion processing capabilities mentioned above. The preeminent element that creates the therapeutic change is the one that empowers a client to develop or unblock the mentioned capabilities. Therapy techniques are sorted by their ability to develop or unblock a certain capability in a particular developmental phase. IPP method conjointly offers an explanatory taxonomy of psychotherapy goals. This taxonomy defines the particular type of learning which takes place in the psychotherapy process and the distinct capabilities that are activated through a certain form of learning.

Taxonomy of  psychotherapeutic goals

The “arsenal“ of capability developing techniques is quite vast, but the psychotherapy techniques are scattered over the different psychotherapy approaches and without a „proper tutorial“ on how to use them, meaning that there isn’t a satisfactory explanation of which technique is meant to be used for what specific problem and when and how it should be applied. In IPP method, we have created a list of techniques originated from various psychotherapy methods (as well as of techniques that we have developed). This list encompasses all the basic emotion processing capabilities associated with the growth assignements, and connects them to the „manual“ on how the techniques can be used to develop certain capabilities.

Nevertheless, in order to make these techniques helpful in developingemotion processing capabilities, it is necessary to apply them through a solid, deep emotional contact with the therapist.

IPP method is not a technique focused therapy. Matteroffactly, IPP method is a „full contact“ approach. Clients identify with fundamental emotion processing capabilities of a therapist through function transference, i.e. procedural learning (direct internalization of emotion processing functions). One might ask „how could clients internalize emotion processing functions of a therapist if they do not know how they therapist feel, what a therapist does with his functions and emotions, what a therapist think while working with a client…? A therapist cannot be a „blank screen“ onto which clients project ther unconscious fantasies, nor he can be a technician who is only proficient in the relevant skills and techniques and one who passes his vast therapy techniques and procedures knowledge onto clients. A therapist is much more than this. A therapist is prone to self-disclosure, yet only when his self-disclosure is beneficial for clients. He discloses only the aspects of himself which encourage clients to develop their fundamental emotional capabilities. This is not an easy job, for it is a lot easier to hide behind the strict psychotherapeutic role. Notwithstanding, the experience I gained through my work with clients has shown and convinced me that “moments of meeting” “(Stern, 1998) between a client and a therapist are key sourses of a change in therapy. “Moments of meeting” or “now moments” (Stern, 1998) within therapy which contain a moment of emotional truth are seen as highly significant. People are changed by other people with whom they are in a close and intimate relationship. They are not changed by using therapy techniques. The core of education in Integrative Psychodynamic Psychotherapy is the capability approach. An IPP psychotherapist is trained to develop their contact capacities and capabilities, which they could only achieve through personal development of their own fundamental emotion processing capabilities, and on top of this, the love and work capabilities.

Why does IPP method pay a particular attention to emotive processing? In order to clarify this procedure, computer-human comparison will again be offered as a model (people are, of course, much more complex systems than computers are). Nevertheless, when a computer has a bug, a user can notice it on its screen. The screen shows unexpected dots, forms or squares… a user is unable to reada text or see a picture at the computer screen. A user who has some basic IT knowledge does not think that the computer screen is broken. Such user knows that something went wrong with the software (which processes the data and creates what is seen at the screen). Such user may also wonder if there is something wrong with the computer hardware (mechanical part of the computer). When people have problems with the “hardware”, they visit their GP’s, neurologists, surgeons, or other specialist for human hardware (i.e. organs). On the other hand, when people experience problems with their software (the data processing program), they seek psychological help.

The states that people seek help for, are actually – the screen – or “clinical picture” as psychologists, psychiatrists and psychotherapists usually call it. Psychotherapists do not deal with hardware, but with the clients’ capabilities and skills that are underdeveloped. Therefore, we cannot fix someone’s self-esteem or depression or impatience or any other unhealthy or dysfunctional state, nor could we create any of pleasurable states if we first do not fix basic emotion and cognitive processing capabilities, capabilities which are meant to process the psychological data, which then will lead to a positive change of a previously unhealthy state.

People create their states by processing what happens to them. The job of a psychotherapist is to help people to develop or unblock the interfering bugs which have created problems in human software. The human software can be seen as an executive emotion processing program. If a software is broken, the psychological problems, previously called “Clinical picture” become evident and manifest.

It is well known that some types of psychotherapies are preferable to some clients, while other people prefer different psychotherapy approaches. What is not totally clear is why does this happen? The answer to this question is much easier when one is introduced with fundamental emotional capabilities andtheir developmental phases. Each therapy technique is created to help the development of a certain capability. Nevertheless, most often we are met with the techniques but not with their proper background. What is lacking is the “tutorial” for the usage of a technique and explanation of what exactly the technique develops.  We are usually met with generalized presumptions such as “how to broaden consciousness” or “how to deal with unaccepted aspects of the self”, or “how to take risks, be more responsible” etc. By defining a technique in this manner, it acquires a status of “general practice technique”. We could compare it to a broad spectrum antibiotic. If a certain therapy technique matches with the developmental need, or a degree to which a specific basic capability is developed, then the antibiotic could heal something and some positive change may happen. If a therapist is empathetic, intuitive and able to maintain a good rapport with a client, the usage of techniques can be helpful.

Intuition is, nonetheless, not transferable. Hence, IPP method offers precise technique selection criteria. These criteria are organized  and based on recognition of a certain fundamental emotional capability developmental status, on a developmental phase of a certain capability. Hence, the clearer understanding of how, when and why we use a therapy technique is established, as well as what and why it can develop, and in which developmental phase a certain technique is going to be helpful.

Nebojša Jovanović

Third Serbian Psychotherapeutic Congress

References:

Akhtar, S. (1987).Schizoid Personality Disorder, American Journal of Psychotherapy, 41 499-518

Akhtar, S. (1990). Concept of Interpersonal Distance in Borderline Personality Disorder (letter to editor).American Journal of Psychotherapy,147 2

Akhtar, S. (1990b). Paranoid Personality Disorder, American Journal of Psychotherapy,44 5-25

Akhtar, S. (1992). Tethers, Orbits, and Invisible Fences: clinical, developmental, sociocultural, and technical aspects of optimal distance. In When the Body Speaks: Psychological Meanings in Kinetic Clues, ed. S. Kramer & S. Akhtar. Northvale, New Jersey
Akhtar, S. (1994). Object Constancy and Adult Psychopathology. International Journal of Psycho-Analysis,75:441-455

Assagioli, R. (1973).The Act of Will. New York: Viking Press

Blum, H. P.,(1981). Object Inconstancy and Paranoid Conspiracy, Journal of the American Psychoanalytic Association.29:789-813
Burngam, D. L., Gladstone, A. E. & Gibson, R. W. (1969). Schizophrenia and the Need-Fear Dilemma, New York: International Universities Press

Erikson, E. (1959).Identity and the Life Cycle. New York: International Universities Press.

Fairbairn, W. R. D., (1952). Psychoanalytic Studies of the Personality, London: Tavistock

Freud, S. (1905). Three Essays on Sexuality.Standard Edition VII. London: The Hogarth Press
Gunderson, J. G., (1985). Borderline Personality Disorder, Washington, DC: American Psychiatric Press.

Guntrip, H. (1969). Schizoid Phenomena, Object Relations and the Self. New York: International Universities Press.

Hartman, D., &Zimberoff, D. (2003).The Existential Approach in Heart-Centered Therapies.Journal of Heart-Centered Therapies, 6(1), 3-46.

Hartmann , H. (1939). Psycho-Analysis and the Concept of Mental Health.International Journal of Psycho-Analysis, 20, 308–321

Hartmann, H. (1950). Comments on the Psycho-analytic Theory of the Ego.’ In: Hartmann 1964Essays on Ego Psychology (London: Hogarth; New York:International Universities Press.)

Hartmann, H. (1952). The Mutual Influences in the Development of Ego and Id In: Essays on Ego Psychology New York: International Universities Press, 1964 pp. 155-182

Ikonen, P. (1998). On Phallic Defense.Scandinavian Psychoanalytic Review, 21:136-150

Klein, M. (1935).A Contribution to the Psychogenesis of Manic-Depressive States, In: Contributions to Psycho-Analysis 1921-1945 London: Hogarth Press, 1948 pp. 282-310

Klein, M. (1940).Mourning and its Relation to Manic-Depressive States, In: Contributions to Psycho-Analysis 1921-1945 London: Hogarth Press, 1948 pp. 344-369

Kohut, H. (1971). The Analysis of the Self. New York: International Universities Press

Kohut , H. (1977). The Restoration of the Self. New York: International Universities Press. Volume 4, p.451-457( “four basic concepts”)

Kris, E. (1951). The Development of Ego psychology. Samiksha, Volume 5

Jovanović, N. (2013).Sposobnostzaljubavi rad-O.L.I. PsihodinamskaIntegrativnaPsihoterapija (tom I, tom II), Beoknjiga, Beograd

Kohut, H. (1971). The Analysis of the Self. New York: International Universities Press

Mahler, M. &Furer, M. (1963). Certain Aspects of the Separation-Individuation Phase.The Psychoanalytic quarterly.32:1-14

Mahler, M. & Furer, M. (1968).On Human Symbiosis and the Vicissitudes of Individuation, New York: International Universities Press

Mahler, M. S. (1974). Symbiosis and individuation: the psychological birth of the human infant. In The Selected Papers of Margaret S. Mahler, Vol. 2, Separation-Individuation New York: Jason Aronson, 1979 pp. 149-165

May, R. (1966).The Problem of Will and Intentionality in Psychoanalysis. Contemporary Psychoanalysis, 3:55-70 ,

Melges, F. T. & Swartz, M. S. (1989). Oscillations of Attachment in Borderline Personality Disorder. American Journal of Psychiatry.146 1115-1120
Rank, O. (1972).Will Therapy, 1929-31. In: Will Therapy and Truth and Reality. New York: Knopf.

Senić, R, Jovanović, N. (2011).Strahodživota – O AnksioznostiiPaničnimNapadima,Beoknjiga: Beograd

Stern, D.N., Sander, L.W., Nahum, J.P., Harrison, A.M., Lyons-Ruth, K., Morgan, A.C., Bruschweilerstern, N. and Tronick, E.Z. (1998).Non-Interpretive Mechanisms in Psychoanalytic Therapy: The ‘Something More’ Than Interpretation.International Journal of Psycho-Analysis. 79:903-921

Winnicott, D. W. (1965). The Maturational Processes and the Facilitating Environment. New York: International Universities Press.

Wolf, E.S. (1980), On the Developmental Line of Selfobject Relations. In: Advances in Self Psychology, ed. A. Goldberg. New York: International Universities Press, pp. 117-130..