Psychoanalysis

Psychoanalysis is a family of psychological theories and methods within the field of psychotherapy that seeks to elucidate connections among unconscious components of patients’ mental processes, and to do so in a systematic way through a process of tracing out associations. In classical psychoanalysis, the fundamental subject matter of psychoanalysis is the unconscious patterns of life as they become revealed through the analysand’s (the patient’s) free associations. The analyst’s goal is to help liberate the analysand from unexamined or unconscious barriers of transference and resistance, that is, past patterns of relatedness that are no longer serviceable or that inhibit freedom. More recent forms of psychoanalysis seek, among other things, to help patients gain self-esteem through greater trust of the self, overcome the fear of death and its effects on current behavior, and maintain several relationships that appear to be incompatible.

History

Psychoanalysis was first devised in Vienna in the 1890s by Sigmund Freud, a neurologist interested in finding an effective treatment for patients with neurotic or hysterical symptoms. As a result of talking with these patients, Freud came to believe that their problems stemmed from culturally unacceptable, thus repressed and unconscious, desires and fantasies of a sexual nature, and as his theory developed, he included desires and fantasies of an aggressive nature, as well. Freud considered these aspects of life instinctive drives, libidinal energy/Eros and the death instinct/Thanatos. Freud’s description of Eros/Libido included all creative, life-furthering instincts. The Death Instinct represented an instinctive drive to return to a state of calm, or non-existence. Since Freud’s day, psychoanalysis has developed in many ways especially as a study of the personal, interpersonal and intersubjective sense of self.

Prominent current schools of psychoanalysis include ego psychology, which emphasizes defense mechanisms and unconscious fantasies; self psychology, which emphasizes the development of a stable sense of self through mutually empathic contacts with other humans; Lacanian psychoanalysis, which integrates psychoanalysis with semiotics and Hegelian philosophy; analytical psychology, which has a more spiritual approach; object relations theory, which stresses the dynamics of one’s relationships with internal, fantasized, others; interpersonal psychoanalysis, which accents the nuances of interpersonal interactions; and relational psychoanalysis, which combines interpersonal psychoanalysis with object-relations theory. Although these schools have dramatically different theories, most of them continue to stress the strong influence of self-deception and the influence a person’s past has on their current mental life.

A few of the most influential psychoanalysts are Jacob Arlow, Charles Brenner, Erik Erikson, Ronald Fairbairn, Sandor Ferenczi, Sigmund Freud, Andre Green, Heinz Hartmann, Carl Jung, Otto Kernberg, Melanie Klein, Heinz Kohut, Julia Kristeva, Jacques Lacan, Margaret Mahler, Stephen A. Mitchell, David Rapaport, Roy Schafer, Daniel N. Stern, Donald Winnicott, Theodor Reik, Harry Stack Sullivan, and Slavoj Zizek.

Theories

Psychoanalysis is theoretically diverse. Most analysts use some selection of the following psychoanalytic models of the mind.

The topographical model

The topographical model of the mind was intended to help analysts understand how patients repress wishes, fantasies, and thoughts. In the topographical model, the mind is divided into conscious, preconscious, and unconscious systems. The conscious system includes all that we are subjectively aware of in our minds. The preconscious includes material that we are capable of becoming aware of, but do not happen to be aware of currently. The unconscious system includes material that we have defensively removed from our awareness by means of repression and other defense mechanisms. In clinical work, analysts try to move unconscious material to the preconscious and then to the conscious mind, to increase the patient’s self-awareness.

The structural model

Perhaps the most famous psychoanalytic model of the mind, the structural model divides the mind into the id, ego, and superego. The id is the source of our motivation, and includes sexual and aggressive drives. The superego includes our moral code and ideals. The ego is made up of a group of mechanisms (reality-testing, judgment, impulse control, etc.) that help us deal with the real world. Analysts who use the structural model commonly focus on helping patients handle conflicts that occur between these three mental agencies. Many also use the structural model for clinical diagnosis. A structural-model diagnosis entails an assessment of the level of functioning of the patient’s id, ego, and superego, and the specific areas of weakness and strength in each. For example, psychoanalysts usually diagnose a patient as psychotic if his or her ego suffers a severe impairment in reality-testing.

The economic model

The economic model of the mind is rarely used today, but is of historical importance. In the economic model, the mind is pictured as an energy system. Mental energy or “libido” may be distributed in a variety of ways thoughout the system, “cathecting” various activities or processes with energy. The vast majority of analysts have abandoned the economic model because it is somewhat vague and relies heavily on nineteenth century ideas about hydraulics. Still, a small number of philosophically minded analysts retain the economic model because they believe that its vagueness is helpful in alluding to features of mental life that may lie beyond scientific understanding.

The conflict model

The conflict model of the mind is designed to help analysts understand specific mental conflicts. This model of the mind divides the mind into basic units called compromise-formations. A compromise formation consists of a wish, a feeling of discomfort about the wish, and a defense used to eliminate that feeling of discomfort. For example, a patient might have an aggressive wish to attack authority figures, fear that if he or she were to do so punishment might result, and defensively intellectualize about general problems with authority rather than physically assaulting his or her superiors. The product of the wish, discomfort, and defense takes shape as a compromise between the three. Some influential analysts have argued that the conflict model is the most important psychoanalytic model, distinguishing psychoanalysis from other psychological theories such as humanistic psychology that minimize mental conflict.

The object-relational model

The object-relational model of the mind describes the mind as structured by internalized relationships with others. This model has it that we all internalize our childhood experiences with other people, and our patterns of thinking, wishing, and feeling are organized by these experiences. Psychoanalysts often refer to the internalized other as an “internal object.” An analyst might use the object-relational model to understand, for example, a patient who seeks out abusive relationships because of an abusive childhood which has taught her that to be loved, he or she must tolerate abuse. The object-relational model is perhaps the most widely used theory among analysts today.

The intersubjective model

The most recently developed model listed here, intersubjective model is closely related to the object-relational model. Intersubjectivity theory tries to capture the complex ways in which the subjective points of view of different people interact. According to intersubjectivity theory, all of our experiences are heavily influenced by the interface between our own subjectivities and those of others. Among other things, the intersubjective model has led many analysts to revise their understanding of the origins of repression and other defense mechanisms. Intersubjectivity theory proposes that between people, intersubjective fields are established in which some experiences can be conscious and some must be kept out of awareness. Defense mechanisms, from an intersubjective perspective, take shape in formative intersubjective interactions in which particular experiences are treated as unspeakable.

Techniques

The basic method of psychoanalysis is the transference and resistance analysis of free association. The patient, in a relaxed posture, is directed to say whatever comes to mind. Dreams, hopes, wishes, and fantasies are of interest, as are recollections of early family life. Generally the analyst simply listens, making comments only when, in his or her professional judgment, an opportunity for insight on the part of the patient arises. In listening, the analyst attempts to maintain an attitude of empathic neutrality, a nonjudgmental stance designed to create a safe environment. The analyst asks that the analysand speak with utter honesty about whatever comes to awareness while interpreting the patterns and inhibitions that appear in the patient’s speech and other behavior.

Freud’s patients would lie on this couch during psychoanalysisA general rule of thumb in psychoanalytic treatment is that more insight-oriented techniques are to be used with healthier patients, whereas more supportive techniques are to be used with more disturbed patients. The most common example of an insight-oriented technique is an interpretation, in which the analyst delivers a comment to the patient that describes one or more cluster of unconscious wishes, anxieties, and defenses. An example of a supportive technique might be reassurance, in which the analyst tries to lower the patient’s level of anxiety by assuring he/she that what he or she fears will not come to pass, or will be manageable. Analysts usually prefer to make more insight-oriented interventions when possible, as they feel that such interventions are usually less judgmental than other techniques.

Currently, most psychoanalysts claim that analysis is most useful as a method in cases of neurosis and with character or personality problems. Psychoanalysis is believed to be most useful in dealing with ingrained problems of intimacy and relationship and for those problems in which established patterns of life are problematic. As a therapeutic treatment, psychoanalysis generally takes three to five meetings a week and requires the amount of time for natural or normal maturational change (three to seven years).

Randomized controlled studies have suggested that psychodynamic treatment is helpful in cases of depressive disorders (4 randomized controlled trials (RCTs)), anxiety disorders (1 RCT), post-traumatic stress disorder (1 RCT), somatoform disorder (4 RCTs), bulimia nervosa (3 RCTs), anorexia nervosa (2 RCTs), borderline personality disorder (2 RCTs), Cluster C personality disorder (1 RCT), and substance-related disorders (4 RCTs). [1]

Much recent psychoanalytic work has been devoted to exploring the use of psychoanalytic principles and techniques in shorter face-to-face psychodynamic psychotherapy, and integrating psychoanalysis with other psychotherapeutic techniques such as those of cognitive behavior therapy. Empirical research on the efficacy of psychoanalysis and psychoanalytic psychotherapy has also become prominent among psychoanalytic researchers. An open-door review of outcome studies of psychoanalysis can be found here

Cost and length

Although psychoanalytic treatment used to be expensive, cost today ranges from as low as ten dollars a session (with an analytic candidate in training at an institute) to over 250 dollars a session with a senior training analyst.

Length of treatment varies. Some psychodynamic approaches, such as Brief Relational Therapy (BRT), Brief Psychodynamic Therapy (BPT), and Time-Limited Dynamic Therapy (TLDP) limit treatment to 20-30 sessions. Full-fledged psychoanalysis, however, may last 3-7 years. Which treatment length is optimal depends on the individual’s needs.

Training

Throughout the history of psychoanalysis, most psychoanalytic organizations have existed outside of the university setting, with a few notable exceptions.

Psychoanalytic training usually occurs at a psychoanalytic institute and may last approximately 4-10 years. Training includes coursework, supervised psychoanalytic treatment of patients, and personal psychoanalysis lasting 4 or more years.

Most psychoanalytic institutes require that applicants already possess a graduate degree. Applicants usually have degrees in clinical social work (MSW or DSW), clinical psychology (PhD or Psy.D), or medicine (MD). A handful of institutes also accept applicants who have graduate degrees in nonclinical disciplines.

An ongoing debate in professional psychoanalysis concerns the prior qualifications candidates must have to enter analytic training. Freud believed that applicants from the humanities and many nonmedical disciplines are as well prepared as physicians for psychoanalytic training. Early in the history of psychoanalysis, prominent analytic organizations tried to limit psychoanalytic training to physicians. Later, after extensive debates and legal battles, psychoanalytic training in most institutes was opened to nonmedical mental health professionals, such as psychologists and clinical social workers. Currently, access to training by appicants from nonclinical disciplines, such as literary studies and philosophy, is limited. A small number of institutes, citing Freud’s belief that training in the humanities provides good preparation for analytic training, admit nonclinical applicants. However, there is an ongoing effort by analysts with prior training in mental health to restrict access to analytic institutes by such applicants, repeating the early monopoly on psychoanalytic training by physicians.

Other definitions

Psychoanalysis is:

• A therapeutic technique for the treatment of neurosis.
• A technique used to train psychoanalysts. A basic requirement of psychoanalytic training is to undergo a successful analysis.
• A technique of critical observation. The successors and contemporaries of Freud—Carl Jung, Alfred Adler, Wilhelm Reich, Melanie Klein, Wilfred Bion, Jacques Lacan, and many others—have developed Freud’s theories and advanced new theories using the basic method of quiet critical observation and study of individual patients and other events.
• A body of knowledge so acquired.
• A clinical theory. See, for example, “Ordinary Language Essentials of Clinical Psychoanalytic Theory” by Wynn Schwartz.
• A movement, particularly as led by Freud, to secure and defend acceptance of the theories and techniques.
• Psychoanalysis involves extended exploration of the self, a realization of the Delphian motto, “Know thyself”. In this it resembles the extended meditative practices of Buddhist monastic schools such as Zen. If successful, it gives a person the capacity to be present in the moment, responding authentically to circumstances, being free of infantile responses inappropriate to the situation.

Today psychoanalytic ideas are imbedded in the culture, especially in childcare, education, literary criticism, and in psychiatry, particularly medical and non-medical psychotherapy. Though there is a mainstream of evolved analytic ideas, there are groups who more specifically follow the precepts of one or more of the later theoreticians.

Psychoanalyses in groups

Though the most commonly held image of a psychoanalytic session is one in which a single analyst works with a single client, ‘group’ sessions with two or more clients are not unknown. Carrying out psychoanalysis in groups can be motivated by economic factors (individual analysis is time-consuming and expensive) or by the belief that clients may benefit from witnessing the various client-client and analyst-client interactions. In most forms of group-based analysis, the group is initially an artefact created by the analyst selecting the various members; the assumption is that the common relationship to the analyst will lead to the formation of a genuine group situation. Group psychotherapy of ‘natural’ groups (e.g. of whole families) seems to be a relative rarity.

Cultural Adaptations

Psychoanalysis can be adapted to different cultures, as long as the therapist or counseling understands the client’s culture. For example, Tori and Blimes found that defense mechanisms were valid in a normative sample of 2,624 Thais. The use of certain defense mechanisms was related to cultural values. For example Thais value calmness and collectiveness (because of Buddhist beliefs), so they were low on regressive emotionality. Psychoanalysis also applies because Freud used techniques that allowed him to get the subjective perceptions of his patients. He takes an objective approach by not facing his clients during his talk therapy sessions. He met with his patients’ where ever they were, such as when he used free association—where clients would say whatever came to mind without self-censorship. His treatments had little to no structure for most cultures, especially Asian cultures. Therefore, it is more likely that Freudian constructs will be used in structured therapy (Thompson, et al., 2004). In addition, Corey postulates that it will be necessary for therapist to help clients develop a cultural identity as well as an ego identity. Since Freud has been criticized for not accounting for external/societal forces, it seems logical that therapist or counselors using his premises will work with the family more. Psychoanalytic constructs fit with constructs of other more structured therapies, and Firestone (2002) thinks psychotherapy should have more depth and involve both psychodynamic and cogitative-behavioral approaches. For example, Corey states, that Ellis, the founder of Rational Emotive Behavioral Therapy (REBT) would allow his clients to experience depression over a loss, such an emotion would be rational—often people will be irrational deny their feelings. Since Freudian constructs can fit with other psychotherapeutic and counseling approaches, it can also be adapted to a variety of cultures, but it can not be employed in its widest use as Freud and Firestone would advocate (Firestone, 2002; Tori and Blimes 2002,).

Adaptations for age and managed care

Play Therapy for different ages

Psychoanalytic constructs can be adapted and modified to both age and managed care through the use of play therapy such as art therapy, creative writing, Sand Tray Therapy, storytelling, bibliotherapy, and analytical psychodrama. In the 1920’s, Anna Freud (Sigmund Freud’s daughter) adapted psychoanalysis for children through play. Using toys and games, she was able to enhance relationship with the child – Freud has been criticized for his, objective and disengaged, approach. When children play, they often engage in a make believe world where they can express their fears and fantasies, and they do so without censorship, so it resembles very much the technique of free association. Psychoanalytic play therapy allows the child and the counselor to access material in the unconscious, material that was avoided and forgotten. This material is re-integrated into the conscience, and the counselor is able to work with the child and the family to address the trauma or issue that was forgotten. With adults, the term art therapy is used, instead of play, however they are synonymous. The counselor simply adapts art therapy to the age of the client. With children, a counselor may have a child draw a portrait of his self, and then tell a story about the portrait. The counselor watches for re-occurring themes – regardless of whether it is with art or toys. With adults, the counselor may work one on one or in a group and have clients do various art activities like painting or clay to express themselves – toys here would not probably not be age appropriate, and children stop pretend play as they transition into adolescence. Since play is considered appropriate in Occidental (Western) culture, it allows people to deal with personal/social issues that they would normally avoid – it allows them to drop their defenses without anxiety and fear.

Other play therapy techniques

Bibliocounseling involves selecting stories from books that children can identify with (similar issues). Through this story, a child will be more likely to not feel defensive and will work to find alternative solutions to problems. Storytelling is similar, the counselor may tell a story but not use a name, and instead he may address the child with each new sentence using his name. For example, He may say, “next, Eric, the little boy had dream about a mouse that was not like the other mice…”

Play therapy for managed care

Unlike traditional psychoanalysis, play therapy takes much shorter time span; which allow insurance companies to cover it for their clients. Even more, it provides more structure to the process allowing for specific measurable goals. Psychoanalytic theory will be applied in more preventative ways, such as educating parents on how to best meet the needs of the child and enhance the child’s development and growth. Lastly, more advocates may use homework assignments such as journal writing to save time (Thompson et al., 2004).

Expressive writing for managed care

According to a book, review by Berman (2003) the writing cure provides an analysis of research that supports expressive writing as a way to integrate cognitions and work through trauma. People who write about traumatic events experience more self control. The Writing Cure offers new, cost-effective ways to treat clients; clients can even use expressive writing to work through their own personal/social issues.

Criticisms

Psychonalysis has been criticized on a variety of grounds by Karl Popper, Adolf Grünbaum, Peter Medawar, Ernest Gellner, Frank Cioffi, Frederick Crews, and others. Popper argues that it is not scientific because it is not falsifiable. Grünbaum argues that it is falsifiable, and in fact turns out to be false. Exchanges between critics and defenders of psychoanalysis have often been so heated that they have come to be characterized as the Freud Wars.

Some defenders of psychoanalysis suggest that its logics and formulations are more akin to those found in the humanities than those proper to the physical and biological sciences, though Freud himself tried to base his clinical formulations on a hypothetical neurophysiology of energy transformations. By the 1970’s, psychoanalytic writers like Roy Schafer and George Klein treated psychoanalysis as two separate theories, one, a theory of energy transformations that lacked empirical validation and the other, an “experience-near” theory of human intentionality that was philosophically independent of the reductionism and determinism of 19th century science as seen in the works of Helmholz and Hobbes. Reductionism and determinism were recognized as contrary to the clinical methods and goals of psychological liberation. Psychoanalysis as a collection of clinical theories was recast as a theory of interpretation and development with a focus on understanding how the varieties of nonconscious dispositions and actions influence a person’s life in the form of transference and resistance.

In a closely related argument, the philosopher Paul Ricouer argued that psychoanalysis can be considered a type of textual interpretation or hermeneutics. Like cultural critics and literary scholars, Ricouer contended, psychoanalysts spend their time interpreting the nuances of language- the language of their patients. Ricouer claimed that psychoanalysis emphasizes the polyvocal or many-voiced qualities of language, focusing on utterances that mean more than one thing. Ricouer classified psychoanalysis as a hermeneutics of suspicion. By this he meant that psychoanalysis searches for deception in language, and thereby destabilizes our usual reliance on clear, obvious meanings. The philosopher Jacques Derrida took a similar position. Derrida used psychoanalytic theory to question what he called the metaphysics of presence, a body of philosophical theory which assumes that the meaning of utterances can be pinned down and made fully evident.

Psychoanalysts have often complained about the significant lack of theoretical agreement among analysts of different schools. Many authors have attempted to integrate the various theories, with limited success. An important consequence of the wide variety of psychoanalytic theories is that psychoanalysis is difficult to criticize as a whole. Many critics have attempted to offer criticisms of psychoanalysis that were in fact only criticisms of specific ideas present only in one or more theories, rather than in all of psychoanalysis. For example, it is common for critics of psychoanalysis to focus on Freud’s ideas, even though only a fraction of contemporary analysts still hold to Freud’s major theses. As the psychoanalytic researcher Drew Westen puts it, “Critics have typically focused on a version of psychoanalytic theory—circa 1920 at best—that few contemporary analysts find compelling…In so doing, however, they have set the terms of the public debate and have led many analysts, I believe mistakenly, down an indefensible path of trying to defend a 75 to 100-year-old version of a theory and therapy that has changed substantially since Freud laid its foundations at the turn of the century.” link to Westen article

An early criticism of psychoanalysis was that its theories were based on little quantitative and experimental research, and instead relied almost exclusively on the clinical case study method. An increasing amount of psychoanalytic research from academic psychologists and psychiatrists who have worked to quantify and measure psychoanalytic concepts has begun to address this criticism.

Research on psychodynamic treatment of some populations shows mixed results. Research by analysts such as Bertram Karon and colleagues at Michigan State University had suggested that when trained properly, psychodynamic therapists can be effective with schizophrenic patients. More recent research casts doubt on these claims. The Schizophrenia Patient Outcomes Research Team (PORT)report argues in its Recommendaton 22 against the use of psychodynamic therapy in cases of schizophrenia, noting that more trials are necessary to verity its effectiveness. However, it has been noted that the PORT recommendation is based on the opinions of clinicians rather than on empirical data, and empirical data exist that contradict this recommendation.link to abstract A review of current medical literature in The Cochrane Library, (the updated abstract of which is available online) reached the conclusion that no data exist supporting the view that psychodynamic psychotherapy is effective in treating schizophrenia. Further, data also suggest that psychoanalysis is not effective (and possibly even detrimental) in the treatment of sex offenders.

Although the popularity of psychoanalysis was in decline during the 1980’s and early 1990’s, prominent psychoanalytic institutes have experienced an increase in the number of applicants in recent years. link to article

References

• Berman, J. (2003). [Review of the book The writing cure: How expressive writing promotes health *and well-being. [Electronic version]. Psychoanalytic psychology, 20(3), 575-578.
• Brenner, C. (1954). An elementary textbook of psychoanalysis.
• Corey, G. (2001). Theory and practice of counseling and psychotherapy. (6th ed.). Belmont, CA: Brooks/Cole Thompson Learning
• Firestone, R.W. (2002). The death of psychoanalysis and depth therapy. [Electronic version]. Psychotherapy: Theory, Research, Practice, and Training, 39(3), 223-232.
• Kramer, Peter D., Listening to Prozac : A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self ISBN 0670841838.
• Luhrmann, T.M., Of Two Minds: The Growing Disorder in American Psychiatry ISBN 0679421912.
• Thomson, C.L, Rudolph L.B., & Henderson, D. (2004). Counseling children. (6th ed.). Belmont, CA: Brooks/Cole Thompson.
• Tori, C.D. & Blimes, M. (Fall 2002). Cross-cultural and Psychoanalytic Psychology: The Validation of defense measure in an Asian population. [Electronic version]. Psychoanalytic psychology, 19(4), 701-421. Psychoanalytic Theory: An Introduction by Anthony Elliott, an introduction that explains psychoanalytic theory with interpretations of major theorists [2]
• The Psychoanalytic Movement: The Cunning of Unreason, by Ernest Gellner. A critical view of Freudian theory. ISBN 0810113708
• Mitchell, S. & Black, M. (1995). Freud and Beyond: A History of Modern Psychoanalytic Thought
• Wachtel, P. (1989). Psychoanalysis and Cognitive Behavior Therapy: Toward an Integration. New York: Basic Books.

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