Preparatory Mindset
Freud's psychodynamic theory underpins the psychodynamic therapy approach. The exam tests: three levels of consciousness (unconscious, preconscious, conscious), three-part personality structure (id, ego, superego), psychosexual stages, defense mechanisms, and the techniques of psychodynamic therapy (free association, dream analysis, interpretation, resistance, transference). The Week 16 questions confirm these are heavily tested.
Exam mindset: know the basic defense mechanisms (repression, projection, denial, transference, rationalization, isolation, displacement, sublimation, intellectualization, reaction formation, regression) — pairing each with an example. Freudian slip = parapraxis.
Core Concepts
1. Three levels of consciousness (MUST KNOW)
- Conscious: what we are currently aware of
- Preconscious (subconscious): what we can become aware of (memory, thoughts just below the surface)
- Unconscious: repressed wishes, fears, conflicts, drives — not directly accessible; influence behavior indirectly (dreams, slips, symptoms)
2. Structure of personality (MUST KNOW)
| Component | Primary | Operates by | Composed of |
|---|---|---|---|
| Id | Pleasure principle | Primary process (irrational, demanding) | Inherited, instincts (Eros — life, Thanatos — death) — present at birth |
| Ego | Reality principle | Secondary process (rational, logical) | Develops from id; mediates between id, superego, and reality |
| Superego | Morality principle | Internalized social/moral standards | Develops from resolving Oedipus/Electra complex (~3-5y); conscience + ego-ideal |
- The personality mediates between primal drives (id) and reality (the Week 16 question — Freud's model of which part mediates between drives and reality → Ego)
3. Psychosexual stages (MUST KNOW)
| Stage | Age | Erogenous zone | Fixation may lead to |
|---|---|---|---|
| Oral | 0–1.5y | Mouth (sucking, biting) | Dependency, oral fixation (smoking, overeating) |
| Anal | 1.5–3y | Anus (bowel control) | Anal-retentive (stingy, obsessive) or anal-expulsive (messy, chaotic) |
| Phallic | 3–6y | Genitals | Oedipus/Electra complex; castration anxiety/penis envy |
| Latency | 6–12y | None (dormant) | Socialization, learning |
| Genital | 12y+ | Genitals (sexual maturity) | Healthy adult sexuality |
4. Defense mechanisms (MUST KNOW — the exam's favorite)
- Repression: involuntary blocking of unacceptable thoughts/impulses from consciousness (the foundation)
- Projection: attributing one's own unacceptable feelings to others ("I don't hate him — he hates me")
- Denial: refusing to accept reality (e.g., patient refuses to accept a serious diagnosis)
- Displacement: redirecting emotions to a safer target (boss yells at me → I yell at my dog)
- Sublimation: redirecting unacceptable impulses into socially acceptable behavior (aggression → sport)
- Reaction formation: transforming unacceptable into the opposite (hate → exaggerated love)
- Rationalization: justifying an action with logical but false reasons (sour grapes)
- Intellectualization: avoiding emotion by focusing on facts/details
- Isolation of affect: separating emotion from the event (describing trauma flatly)
- Regression: reverting to an earlier developmental stage under stress (adult tantrum)
- Splitting: seeing people as all good or all bad (borderline personality)
- Suppression: conscious voluntary pushing away of thoughts (unlike repression)
- Mature defenses: sublimation, suppression, altruism, humor
- Immature: projection, denial, regression, splitting, acting out
- Psychotic: distortion, denial of external reality
- Neurotic: repression, reaction formation, displacement, intellectualization
5. Psychodynamic therapy — techniques (MUST KNOW)
- Free association: patient says whatever comes to mind without censorship — the data source
- Dream analysis: dreams as the "royal road to the unconscious" — manifest (story) vs. latent (unconscious meaning)
- Interpretation: therapist explains the meaning of patient's free associations, dreams, and behavior
- Resistance: patient's unconscious avoidance of facing painful thoughts (e.g., missing sessions, blocking)
- Transference: patient unconsciously redirects feelings about past people onto the therapist (e.g., feeling anger toward therapist as toward a parent)
- Countertransference: therapist's emotional response to the patient (must be monitored)
- Working through: the main therapeutic work — repeatedly facing the conflict across many sessions
- Therapeutic alliance: collaborative relationship between therapist and patient
- Parapraxis (Freudian slip): speech error revealing unconscious wish ("I didn't mean to say that")
6. Phallic stage — Oedipus/Electra complex
- Oedipus complex (boys): desire mother, fear father (castration anxiety) → identification with father → resolved by ~5-6y → superego formation
- Electra complex (girls): analogous (penis envy, identification with mother)
- Modern view: the central concept is the formation of the superego (moral conscience) — not the literal sexual content
7. Modern psychodynamic
- Object relations theory: Klein, Winnicott — focus on early relationships and internal representations
- Self psychology (Kohut): self-esteem, mirroring, idealizing
- Attachment theory (Bowlby): links to object relations (see Ch04)
- Limitation: less empirically testable; better evidence for CBT and other short-term therapies
8. Clinical relevance
- Understanding transference: essential in any long-term therapy — don't act on the patient's projections
- Defense mechanisms in medicine: recognize denial in terminal illness, displacement in angry patients, rationalization in substance abuse
- Brief psychodynamic therapy: now evidence-based for depression, anxiety
High-Yield Points
- 3 levels: unconscious, preconscious, conscious
- 3 personality parts: id (pleasure), ego (reality), superego (morality) — ego mediates primal drives and reality
- Psychosexual stages: oral → anal → phallic → latency → genital
- Ego defenses (top 10): repression, projection, denial, displacement, sublimation, reaction formation, rationalization, intellectualization, isolation, regression
- Transference = patient redirects feelings from past to therapist; Countertransference = therapist's response
- Therapy techniques: free association, dream analysis (manifest/latent), interpretation, working through
- Free association = saying whatever comes to mind without censorship
- Oedipus/Electra complex → superego formation
- Freudian slip = parapraxis reveals unconscious
- Mature (sublimation, humor) vs immature (projection, denial) vs psychotic (distortion)
Topic Summary
Freud's psychodynamic theory describes the mind in three levels of consciousness (unconscious, preconscious, conscious) and three personality structures — id (pleasure principle, primary process), ego (reality principle, mediates drives and reality), and superego (moral conscience, internalized standards). Personality develops through psychosexual stages (oral, anal, phallic, latency, genital), with fixation leading to adult character patterns. Defense mechanisms (10 core: repression, projection, denial, displacement, sublimation, reaction formation, rationalization, intellectualization, isolation, regression) protect the ego from anxiety. Psychodynamic therapy techniques include free association, dream analysis (manifest vs. latent content), interpretation, resistance, transference (patient → therapist), and countertransference (therapist's response). The Oedipus/Electra complex drives superego formation in the phallic stage. Modern psychodynamic approaches (object relations, self psychology, attachment) emphasize early relationships and the therapeutic alliance, with brief psychodynamic therapy now evidence-based for common disorders.
LMCHK OSCE Practice
- Defense mechanics identification: ask the patient to describe a recent conflict → identify which defense (e.g., "I was angry at my boss but I came home and yelled at my dog" — displacement).
- Breaking bad news (SPIKES): A — Acknowledge; S — Strategy; K — Knowledge ("I wish I had better news…"); I — Invite; E — Emotions; S — Summarize — addresses denial and emotion.
- Identify denial in terminal illness: recognize and gently confront ("Tell me what you understand about your illness").
- Countertransference self-check: note your own emotional reactions to the patient — discuss with supervisor; withdraw from the case if needed.
- Therapeutic alliance: build rapport before addressing difficult topics; the alliance predicts outcome better than technique.
- Suicidal patient: safety plan (mean restriction, remove means, no-suicide contract), involve support, urgent referral.
- Free association example: ask the patient to say the first thing that comes to mind about a word (e.g., "mother" — "warm / worry / angry").
- Distinguish mature vs immature defenses: sublimation (mature) vs acting out (immature) — guide the patient to mature defenses.
- Transference / countertransference: recognize the phenomenon — the patient's anger toward the therapist without current cause (transference) or the therapist's over-identification (countertransference); discuss in supervision.
- Psychoeducation about medication: patient may deny/devalue treatment ("I don't need pills") — address the denial, explain the disease, use insights from motivational interviewing.