24th October 2023

Dreams, Defence Mechanisms, and Models of the Mind

Dreams

The most likely aspects to be tested on in your MRCPsych Paper A exam will be the definitions of the methods used by, and conceived by, Freud in relation to his psychoanalytic practice and work on dreams. These terms are all underlined in this section of the chapter, but included is some background to Freud and his theories to provide you with context to help better understand them and his thinking.

Sigmund Freud

Following medical school, Freud trained first as a neurologist, including a year of study in Paris with Jean-Martin Charcot (known for Charcot’s triad, foot, etc.). He was also influenced by a couple of other clinicians who both taught him hypnosis. After this, he returned to Vienna and began clinical work with hysterical patients. In collaboration with Joseph Breuer, an older and well established clinician, they treated a woman, referred to as Anna O, using hypnosis. They noticed that in this hypnotic trance state, the patient could relive a traumatic event and consequently release the associated emotions, a process they called abreaction. This, however, did not work on all patients, with some unable to access their memories during this process. Freud referred to this as resistance, which felt to be caused by the unconscious process of repressing such memories. Subsequently, he switched to adopt a technique called free association whereby the patient was encouraged to say whatever came to their mind.

Interpretation of dreams

During Freud’s clinical sessions, he noted patient’s dreams were often brought up during free association, and so in his landmark publication, The Interpretation of Dreams (1900), Freud proposed a theory that dreams were partly an experience of expressing repressed impulses or wishes. He also noted that dreams could include fragments of day residue (thoughts and preoccupations of the dreamer’s current life) and nocturnal sensory stimuli (pain, hunger, urge to pass urine).

Freud distinguished dreams into two layers – manifest and latent content. Manifest content is what could be recalled on waking by the dreamer, whereas latent content is the unconscious thoughts and wishes that threaten to wake the dreamer. Dream work was defined as the unconscious process of transforming latent content into manifest content.

Freud also described various different processes that could occur during dreams; he referred to these as the four primary process mechanisms:

Condensation – The mechanism of combining several unconscious wishes, impulses or attitudes into a single image in the manifest dream content. An example of this would be a scary monster (the image) appearing in a child’s nightmare, representing the unification of various people in their life (parents, teachers, bullies) as well as possibly their own repressed feelings (anger, frustration).

Irradiation/diffusion – This is the opposite of condensation, where a single unconscious wish, impulse or attitude is distributed into multiple images in the manifest content of the dreamer.

Displacement – The mechanism of transferring energy (cathexis) or feelings from an original object (e.g. the dreamer’s mother) onto a more neutral, symbolic representation of the object (e.g. an unknown female). The purpose of this is to obtain the dreamer’s repressed thoughts or impulses related to the mother.

Symbolic representation – The representation of intense ideas or complex feelings towards a person in the form of a simple or innocent image that was in some way connected to the idea or object involved.

Secondary revision

Primary process dreams were expressed as strange, unusual, or abstract images that were difficult to understand. When dreams became easier to understand and more rational, he referred to the process as secondary revision. This was felt to be related to more mature activity and thoughts during waking life.

Types of dreams

Affect in dreams – Secondary emotions could be completely absent from dreams, appear as their opposite feeling, or occur in an altered manner.

Anxiety dreams – Freud saw the primary processes and secondary revision mechanisms as a way to release unconscious impulses. If the dreamer had anxiety in their manifest content, then he felt these mechanisms had failed in their function to protect the dreamer.

Punishment dreams – Freud felt a dream containing the experience of punishment represented a compromise between a repressed wish and the conscience (responsible for repressing the impulse). The repressed wish for punishment is satisfied by the expression of punishment fantasies in manifest dream content.

References

• Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Kaplan and Sadock’s Synopsis of Psychiatry:
• Behavioral Sciences/Clinical Psychiatry (11th ed.). Wolters Kluwer. 153-154.

Defence Mechanisms

It is very likely that you’ll be tested on your understanding and application of the defence mechanisms in your EMQs (also possibly in the SBAs). It is common for you to be given an example of a patient and their use of a specific defence mechanism in a particular situation, with you expected to choose the mechanism being used by the person. Similar types of questions will be included for you to practise at the end of the chapter.

Defence mechanisms are unconscious strategies used by the person (or mind) to protect itself in situations of overwhelming emotion, such as anxiety or stress. They can be thought of as a way to explain a variety of human behaviours or experiences that can occur both in the presence or absence of psychopathology.

Anna Freud was responsible for naming what was originally thought of as the Freudian defences before more were added by Klein (see brackets) and others. Vaillant was responsible for classifying and organising them into the subcategories of mature, immature and neurotic defences. Below, you can find descriptions and examples of the most commonly found defence mechanisms:

Mature defences

(Use this mnemonic to remember – SASHA)

Sublimation – The transfer of perceived unhelpful impulses or sexual urges onto more socially acceptable or productive alternatives, for example, guilt being transferred into charity work. It is suggested that Freud sublimated his sexual desires by devoting his life to science.

Altruism – Describes the mechanism of fulfilling one’s own needs through a dedication to the lives of others and their needs. By using this defence mechanism, the person receives partial gratification, either directly or indirectly.

Suppression – A temporary voluntary avoidance of engagement with a conscious feeling or stressor in order to postpone dealing with it at present. There is an acknowledgement of emotional discomfort, but the person can continue focusing on a more pressing task or thought until the suppressed material is ready to be returned.

Humour – The use of comedy by emphasising certain amusing or ironic aspects of a particular stressor or event in order to relieve tension. It serves to outwardly express thoughts and feelings in a situation with everyone rather than at the expense of a single person.

Anticipation – The process of planning for future distress or stressors by using mental preparation to mitigate the effects and consider realistic, alternative solutions. The future distress is experienced, allowing rehearsal to prepare an adaptive response to the stressor.

Immature defences

Acting out – The process of acting with disregard or thought about the negative personal or social consequences. It is used to expel troublesome feelings rather than deal with them. The person will often feel guilty after, on reflection, after the event.

Passive aggression – The act of indirectly and non-assertively expressing anger towards others through passive activities. It is characterised by venting hostile or resentful feelings indirectly towards others.

Projection (sometimes called a narcissistic defence) – Defined as falsely attributing anxieties, impulses or stressors to an external origin, for instance, onto another person’s actions. Thus, internal threats become externalised and then are easier to cope with.

Somatisation – Psychological distress is converted into physical distress and expressed as bodily symptoms.

Somatosensory amplification – The experience of magnifying bodily sensations as particularly intense or upsetting, thought to form the basis for somatisation and somatoform disorders.

Melanie Klein was a psychoanalyst who developed an approach to defence mechanisms that focused on the ways in which individuals cope with internal conflicts and anxieties. Klein believed that defence mechanisms were an important part of the human psyche and that they could be seen as unconscious processes that helped individuals manage their emotions and deal with difficult or threatening situations. Klein believed that defence mechanisms were primarily developed in childhood as a way for individuals to deal with the anxieties and conflicts that arise from their relationships with others, particularly their parents. She also emphasised the importance of the internalisation of object relations in the formation of defence mechanisms. Below are examples of the main ‘Kleinian’ defences; you can use the mnemonic ‘SIIPDDOG’ to remember them more easily:

Splitting – The act of viewing oneself or others as all good or bad, with the failure to integrate the positive and negative attributes into a coherent whole picture of the person. This is usually learned from inconsistency from caregivers in early life. This is commonly seen in those with emotionally unstable personality disorder.

Idealisation – Exaggerating the positive attributes of one’s self or others in order to protect against feelings of powerlessness and unimportance. These feelings can also be attributed to organisations or belief systems, not just individual people.

Introjection – This defence involves internalising external objects or experiences, often in an attempt to gain control over them. For example, a child who is abused by a caregiver may internalise the abuser’s behaviour as a way to gain a sense of control over the situation.

Projective identification – The process of projecting an aspect about oneself onto someone else, with the attempt to convince the person that this originated in them. This may lead to the other person mistakenly believing that this is the truth and, therefore, may behave in a similar manner to the projector.

Devaluation/denigration – Exaggerating the negative attributes of one’s self or others in order to boost self esteem or avoid disappointment.

Denial (sometimes called a narcissistic defence) – Defined as the refusal to acknowledge some aspect of external reality that would be apparent to others. It may persist despite repeated reiteration of the facts. The term denial is often used inappropriately for the knowing or conscious avoidance of painful topics or thoughts.

Omnipotence – The act of behaving in a superior way to others, usually as a result of lowered self esteem or feelings of helplessness.

Grandiosity – Overcompensating for feelings of inferiority or insecurity by developing an exaggerated sense of self-importance or superiority. This can manifest as arrogance, fantasies of power and success, and/or entitlement. It can be seen as a way for individuals to protect themselves from feelings of inadequacy or vulnerability by creating a false sense of superiority. However, it can also lead to interpersonal conflicts and a lack of empathy for others.

Neurotic defences

Displacement – The process of redirecting an unpleasant feeling or response from an object onto another, usually less threatening, one. The feeling is fully expressed but is misdirected to a target that is perceived as less threatening.

Dissociation – Temporary altering of a person’s own identity or consciousness to avoid significant emotional distress. Dissociated material is often perceived as too threatening or anxiety provoking to be allowed into awareness.

Identification with the aggressor – Whereby a person adopts the behaviour and values of an aggressor to feel safe or powerful. It can be seen in abusive relationships, workplace environments, or marginalised groups. While it may provide temporary relief, it can cause harm in the long term.

Intellectualisation – The excessive use of abstract thinking to avoid disturbing feelings. The person distances themselves from the emotional aspects of an idea by using generalisation to minimise the importance of their inner feelings on the problem.

Isolation of affect – The separation of the cognitive and affective aspects of an experience. The person is able to remember details of a likely traumatic event but does not experience the associated painful feelings. This is the converse of repression.

Rationalisation – Seeking to logically explain or find justification for a behaviour or attitude that is felt to be unacceptable.

Reaction formation – Refers to the denial of an unacceptable impulse or thought by replacing it with the opposing behaviour. This substitution occurs unconsciously.

Regression – Falling back to childish behaviours/feelings in order to avoid dealing with a conflict or overwhelming stress.

Repression – Defined by the unconscious forgetting of disturbing feelings or memories in order to protect the self from past experiences. There is some overlap with denial.

Undoing – The use of specific behaviours or rituals to symbolically alleviate unpleasant or uncomfortable thoughts and/or feelings. This is commonly seen in OCD.

References

• Di Giuseppe, M., & Perry, J. C. (2021). The Hierarchy of Defense Mechanisms: Assessing Defensive Functioning With the Defense Mechanisms Rating Scales Q-Sort. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2021.718440
• Casey, P. & Kelly, B. (Ed) Fish’s Clinical Psychopathology. (3rd ed.). RCPsych publications. Appendix II, 129-130.
• Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (11th ed.). Wolters Kluwer. 161-162.

Models of the Mind

Freud’s theory of how the mind was structured developed over time, along with his clinical practice. He moved from the topographical model to instinct/drive theory before settling on his structural theory of the mind. We’ll cover how he theorised the mind was divided, including the function of each aspect and how these models developed and changed over time. Let’s first look at the topographical model:

Topographical model

Within The Interpretation of Dreams, Freud also covered his first theory on how the mind was divided. In this topographical model, the mind was split into – The conscious system, the preconscious system, and the unconscious system. These are elaborated on below:

The conscious system

• Brings perceptions from the body and mind into awareness.
• Communicates contents by language and behaviours only.
• Freud believed consciousness utilised a form of psychic energy, referred to as attention cathexis, to process ideas or feelings.

The preconscious system

• Contents and processes that are able to be brought into awareness by the focus of attention.
• Acts as an interface between the conscious and unconscious systems.
• Acts to maintain the ‘repressive barrier’ to keep unacceptable or unpleasant memories, desires, or impulses out of awareness.

The unconscious system

• Contents are kept out of awareness by repression.
• Governed by the pleasure principle to seek pleasure and avoid pain.
• Characterised by primary process thinking, with the aim of fulfilling desires.
• Felt to be closely linked to both one’s instinctual sexual and self protective drives.
• Can only enter awareness by transferring through the preconscious system first.

Limitations of the topographical model

Freud realised that the use of defence mechanisms (denial, displacement, repression, etc.) to protect oneself from unpleasant or distressing feelings, thoughts, or desires was not utilised in awareness and, therefore, not accessible by the conscious system. This meant that his theory of repression and the preconscious system being the same was not viable, as content in the preconscious system should be able to be brought into the conscious system by the focus of attention. Secondly, Freud also observed that his patients would often express an unconscious need for punishment. This conflicted with the theory that the unconscious, in part, was linked to the self protective drive to avoid pain.

Instinct/drive theory

Following the topographical model, Freud focussed on instinct theory, using mainly biological terms, which raised some problems when describing psychological constructs. In biological terms, instinct defined behaviours that were genetically derived, whereas in modern research, instinctual patterns are learned through experience. Instinct and drive are used interchangeably in modern terms. Freud’s theory of instinct was split into four principal aspects:

Source – The part of the body from where the instinct comes from.

Impetus – The amount of intensity related to the instinct.

Aim – Any actions related towards discharging tension of or fulfilling the wish of the instinct.

Object – The target of the above action(s).

Instincts

Libido – Freud defined libido as the ‘force by which the sexual instinct is represented in the mind’. He recognised that libido did not begin fully formed in the mind, and rather, it underwent a long and complex process throughout psychosexual development.

Ego – Freud theorised that there were both sexual instincts and ego instincts related to self-preservation. He felt there was both an ego libido and an object libido. Any narcissistic elements were considered as related to libido, and the remaining non-sexual aspects were part of the ego instinct.

Aggression – In modern psychoanalysis, dual instinct theory refers to libido and aggression. However, Freud thought of aggression as part of the sexual instincts in the form of sadism. Realising that there were non-sexual aspects to aggression, he later placed these (including hate) as part of the ego instinct and any sadistic parts as sexual instinct. Later, he further defined this with aggression being its own separate instinct, with the source being skeletal muscles, and the aim was for destruction.

Life and death – Freud referred to these as eros (life) and Thanatos (death). These were thought to underlie both the sexual and aggressive instincts, with Freud believing the dominant force in biological terms being thanatos.

Pleasure and reality principles

In 1911, Freud redefined his primary and secondary process theory into pleasure and reality principles. The pleasure principle is the ingrained process of aiming to avoid pain and seek pleasure. The reality principle, instead, is a learned process associated with mature development and is based on the idea of delayed gratification.

Structural model

In his 1923 publication, The Ego and the Id, Freud moved from the topographical model to further develop his theories of the reality and pleasure principles with the structural model of the mind, a theory that is still maintained today in modern psychology. In this model, he divided the mind into the id, ego, and superego. These are elaborated on below:

Id

This contains our instinctual drives present from birth, including both the life (eros) and death (thanatos) instincts (as above). It operates on the pleasure principle and is unable to make changes to or delay these inbuilt drives.

Ego

Felt to contain all three of the conscious, preconscious, and unconscious systems from the topographical model. As part of the conscious and preconscious, it is responsible for verbal expression and different forms of thinking (logical / abstract). It also contains the defence mechanisms, as covered in the previous section, which are in the unconscious part. It operates on the reality principle and processes decisions by moderating between the instinctual drives of the Id and the stimuli the ego receives from the outside world.

Superego

In control of maintaining an individual’s morals based on ideas and values learned from their parents around age 5/6. The superego continues to examine one’s behaviour and thoughts, comparing against expected standards and providing positive or negative feedback (e.g. feelings of guilt). This occurs mostly unconsciously but, interestingly, can be thought of as what we would commonly call our ‘conscience’.

Analytic psychology

Carl Jung, a Swiss Psychiatrist who had initially worked with Freud, formed his own school of psychoanalysis known as analytic psychology. In this, he related to and widely expanded on Freud’s theories of the mind. The main aspects of this work are defined and elaborated on below:

Personal unconscious – Interchangeable with Freud’s unconscious, containing an individual’s repressed, ignored, or forgotten experiences.

Collective unconscious – Jung expanded on unconsciousness to define a common collective unconscious that includes all of humankind’s shared mythological and symbolic past. Within this are what he called archetypes – defined as representative symbolic images that are universally known and understood throughout modern society (e.g. explorer, caregiver, outlaw).

Archetypes – Archetypes also exist for the roles of father, mother, child, and many more. These are felt to impact the development of complexes; for example, a mother complex would occur from the conflict between an archetypal expectation of what it is to be a mother vs the real life experience of being a parent and the interaction with their child.

Introversion/extroversion – Jung was responsible for noticing and naming the contemporary terms of introversion and extroversion, with these being the two types of personality organisation. As you’ll be aware, introverts tend to focus inward on their own thoughts and feelings rather than the external world, whereas extroverts engage more with this, including people and objects. In general, people are a mixture of both personality types.

Other concepts

Jung defined several other concepts to illustrate and explain different facets of personality and how we display these to the outside world. The basic principles are detailed below:

Persona – A mask covering personality which represents the ‘face’ shown to the outside world.

Anima – The unconscious feminine side of man.

Animus – The unconscious masculine side of a woman.

Individuation – The main aim of analytical therapy is to achieve adaptation to reality and fulfilment of creative potential. The ultimate goal is to reach individuation. This involves a person developing their own unique sense of identity via integration of their personality, undeveloped psyche, and external experiences into a well functioning whole.

References

• Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Kaplan and Sadock’s Synopsis of Psychiatry:
• Behavioral Sciences/Clinical Psychiatry (11th ed.). Wolters Kluwer. 154-160, 179-180.