The clinical (illness model) of personality typology #Freud in the therapeutic setting


It was great to get back to term time lectures again last night even if it was not great to be back in the London climate.  I left Valencia (see above) on Monday when it was 37 degrees.  Last night’s lecture was on Freud.    I will be discussing Freud’s ideas later in the week but I wanted to continue my theme of applying personality typology to the therapeutic environment.

In the psychotherapeutic community we owe a great debt to Freud who was primarily concerned with exploring the personal unconscious. The clinical model has its origins in Freud and covers four types: schizoid, obsessional, depressive and hysterical.

Schizoid

In this model this type is described as introverted.  They are more likely to be avoidant in relationships and are fixated on oral development.  This type often fails to turn up for therapy. The defining feature is the distance between the conscious personality and the
feelings function.  There is very little sense of self and there is a fear of intimacy with this type. The schizoid likes to be alone and is not very good with manifestation.

The approach in therapy is to understand that fantasy is the way into feeling for
this type.  Patience is therefore needed in the therapeutic environment, as perhaps it is needed with all clients, but especially so here.  It is perhaps an over generalisation that this type is represented by ‘air’ in the elements model but it can feel like it when you are sitting and listening to a client who speaks non stop in an avoidant manner. With a contracted client, I would slowly try to ground them by getting them to relax and get in touch with their feelings. A number of transpersonal techniques could eventually be employed
when it is safe such as the pebble exercise, meditation, creative imagination
and deep breathing.

Obsessional

 The obsessional type is also described as introverted. The issue with this type is
control, therefore, this type is less likely to turn up for therapy. The feelings are not shown.  They are there, just that they are not shown. This type is associated with the “stiff upper lip”.  Obsessive compulsive disorder (OCD) can be a presenting issue which is about mastering, a form of control.  In Freudian terms, it emanates from a potty
training issue and a form of distortion which took place around 6-18 months
leading to a fixation.

Attempts at control and people pleasing leads to resentments with this type. Spiritual
experience can threaten them.   This type is more likely to become tyrants, controlling
their world through their will and ultimately leading to isolation.

An approach in therapy would be to investigate what is happening in dreams as obsessives
play out sabotage.  The real work in therapy is to uncover what is really going on.
No less with this type. How can the true feelings be revealed? I would seek to explore the source of the resentments and the need for controlling behaviour. The key is to get behind the primary behaviours to uncover what is really going on.

Depression

Depression can be endogenous, reactive and bi-polar (previously called manic). This type in this model is extroverted as the feelings are shown.  There are lots of water qualities. They are more likely to turn up for therapy because of their extraversion inclinations.

Endogenous depression is not a type of depression rather it is biological depression. The defining characteristics are helplessness and hopelessness. What is behind this is an internalised sense of not feeling good enough.  They seek out scripts that are self-deprecating as they are seeking to have their poor self image reflected back to them. 

The manifestations of low self-esteem usually bring them into therapy.  Unlike schizoids, there is a sense of self, but it is lacking or weak.

Reactive depression specifies that depression comes from some event or some stress occurring. For example, problems in a relationship, bereavement, loss of a loved one, changing job or anything that directly affects one’s life.  Other people can sense the
vulnerability of depressives and can seek to exploit their victim status. This is a major liability in dealing with life’s problems since in the workplace there are invariably bullies lurking to pick up on any vulnerability.

Depressives are water types in the elements model as there is distortion.  The water is stagnant.  Bi-polar (formerly termed manic) depression is the toughest to live with and requires medication for chemical rebalancing. Bi-polar clients can be as high as a kite and can be very sexual, or spendaholics. But then there is a crash.  It is about extremes with this type. If they are challenged they can be very defended.  Lithium is the usual
prescribed medication.

The approach in therapy is to be aware of boundaries which are very important for depressed  clients.  CBT interventions such as “to do lists” can be very useful. They need
accurate mirroring and reassurance and require an acknowledgement of their
accomplishments.  It can be safer to access anger (fire) through creativity, in the form of gestalt therapy or working with images. Fire is the expressed form of the water element as the depressed feelings can be akin to stagnant water.

I find the description of this type in this typology limiting in that I believe we are all a bit depressed, to a greater or lesser degree.  How, for example, can you distinguish between sadness of true feelings, perhaps in response to a harsh event, and the sadness brought about by depression?   Perhaps it is best to think in terms of extreme distortion with this type.   We might all be a bit depressed at times but the issue is when the depressed feelings become our defining quality.

Hysterical

Like depressives, hysterics are more likely to turn up for therapy because of the extraversion in these types.  They are extrovert because the feelings are
being displayed (symbolically) and they are demanding attention. In Freud’s day,
the hysterical type was seen as classically female. Hysterical types seek
attention by whatever means. They are invariably still raging at a parent.  They need attention but the right kind.  These are the type that will commit suicide
by accident. The suicide attempt is really a cry for help, for attention, but it
went too far.

There is always a drama going on with them.  Hysterical types are prone to sexually provocative behaviour or to sexualizing non-sexual relationships. However, they may not really want a sexual relationship; rather, their seductive behaviour often masks their wish to be dependent and protected. They have a tendency to “make mountains out of mole hills.”  The proverb rings true: ”Empty vessels make most noise.”

The strategy with this client is to try to find what is really going on and therefore one needs compassion.  They can be hard to like as they seem to be sabotaging themselves.  They are like a hurt child running the show and are distorted earth types.  They look
fiery, but it’s more like an earthquake or a volcano. The presenting issues
with these clients can entail bad physical conditions. Physical holding can be
a positive reassurance, such as a hand on back, a hug, or a holding hand.

Critique of clinical model

Freud has contributed a great deal to our profession but the psychoanalyst tends to have
the role of the wise initiate who ‘knows’ and disagreement would be seen
usually as a defence or a manifestation of pathology. This is at odds with the
transpersonal school, which most certainly does not ‘know’ but finds creativity
in holding and exploring the mystery.  The clinical model can be useful when seeing extreme, distorted types.  It is an illness model and the conflict is the need to conform to society. I would contend that the need to conform to society is less of an issue nowadays.

There are wide differences of opinion within the transpersonal community
as to the appropriateness of doing transpersonal work with psychotic
individuals. Jung, Wilber, and Grof and Grof  have argued that transpersonally oriented therapies are not appropriate for psychotic individuals.  Lukoff and others, however,  suggest that transpersonal psychotherapy may be particularly appropriate for psychotic disorders, even serious ones. In general, initial evaluation should include not only the usual elements of a psychiatric history, but also an assessment of the patient’s spiritual experiences, developmental level, premorbid functioning,  and interest in exploring the symptoms.

More on Freud soon…..

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About Noel Bell

Psychotherapist in London. Check out my blog posts and more at www.noelbell.net
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