Psychoanalysis
From Wikipedia, the free encyclopedia
Psychoanalysisis a body of ideas developed by Austrian Physician Sigmund Freud and continued by others. It is primarily devoted to the study of human psychological functioning and behavior, although it also can be applied to societies.
Psychoanalysis has three applications:
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a method of investigation of the mind;
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a systematized set of theories about human behaviour;
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a method of treatment of psychological or emotional illness.[1]
Under the broad umbrella of psychoanalysis there are at least twenty-two different theoretical orientations regarding the underlying theory of understanding of human mentation and human development. The various approaches in treatment called "psychoanalytic" vary as much as the different theories do. In addition, the term refers to a method of studying child development.
Freudian psychoanalysis refers to a specific type of treatment in which the "analysand" (analytic patient) verbalizes thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the unconscious conflicts causing the patient's symptoms and character problems, and interprets them for the patient to create insight for resolution of the problems.
The specifics of the analyst's interventions typically include confronting and clarifying the patient's pathological defenses, wishes and guilt. Through the analysis of conflicts, including those contributing to resistance and those involving transference onto the analyst of distorted reactions, psychoanalytic treatment can clarify how patients unconsciously are their own worst enemies: how unconscious, symbolic reactions that have been stimulated by experience are causing symptoms.
History
1890s
The idea of Psychoanalysis was developed in Vienna in the 1890s by Sigmund Freud, a neurologist interested in finding an effective treatment for patients with neurotic or hysterical symptoms. Freud had become aware of the existence of mental processes that were not conscious as a result of his neurological consulting job at the Children's Hospital, where he noticed that many aphasic children had no organic cause for their symptoms. He wrote a monograph about this subject.[2] In the late 1880s, Freud obtained a grant to study with Jean-Martin Charcot, the famed neurologist and syphilologist, at the Salpêtrière in Paris. Charcot had become interested in patients who had symptoms that mimicked general paresis, the psychotic illness that occurs due to tertiary syphilis. Charcot had found that many patients experienced paralyses, pains, coughs, and a variety of other symptoms with no demonstrable physical cause. Prior to Charcot's work, women with these symptoms were thought to have a wandering uterus (hysteria means "uterus" in Greek), but Freud learned that men could have psychosomatic symptoms as well. He also became aware of an experimental treatment for hysteria utilized by his mentor and colleague, Dr. Josef Breuer. The treatment was a combination of hypnotism and catharsis which utilized abreaction (ventilation of emotion). This treatment was used to treat the hysterical symptoms of Dr. Breuer's now famous patient, Anna O.
Freud's first theory to explain hysterical symptoms was the so-called "seduction theory." Since his patients under treatment with this new method "remembered" incidents of having been sexually seduced in childhood, Freud believed that they had actually been abused only to later repress those memories. This led to his publication with Dr. Breuer in 1893 of case reports of the treatment of hysteria.[3] This first theory became untenable as an explanation of all incidents of hysteria. As a result of his work with his patients, Freud learned that the majority complained of sexual problems, especially coitus interruptus as birth control. He suspected their problems stemmed from cultural restrictions on sexual expression and that their sexual wishes and fantasies had been repressed. Between this discovery of the unexpressed sexual desires and the relief of the symptoms by abreaction, Freud began to theorize that the unconscious mind had determining effects on hysterical symptoms.
His first comprehensive attempt at an explanatory theory was the then unpublished Project for a Scientific Psychology in 1895.[4] In this work Freud attempted to develop a neurophysiologic theory based on transfer of energy by the neurons in the brain in order to explain unconscious mechanisms. He abandoned the project when he came to realize that there was a complicated psychological process involved over and above neuronal activity. By 1900, Freud had discovered that dreams had symbolic significance, and generally were specific to the dreamer. Freud formulated his second psychological theory – that of there being an unconscious "primary process" consisting of symbolic and condensed thoughts, and a "secondary process" of logical, conscious thoughts. This theory was published in his 1900 opus magnum, The Interpretation of Dreams.[5] Chapter VII was a re-working of the earlier "Project" and Freud outlined his "Topographic Theory." In this theory, which was mostly later supplanted by the Structural Theory, unacceptable sexual wishes were repressed into the "System Unconscious," unconscious due to society's condemnation of premarital sexual activity, and this repression created anxiety. Freud also discovered what most of us take for granted today: that dreams were symbolic and specific to the dreamer. Often, dreams give clues to unconscious conflicts, and for this reason, Freud referred to dreams as the "royal road to the Unconscious."
1900–1940s
This "topographic theory" is still popular in much of Europe, although it has been superseded in much of North America.[6] In 1905, Freud published Three Essays on the Theory of Sexuality[7] in which he laid out his discovery of so-called psychosexual phases: oral (ages 0-2), anal (2-4), phallic-oedipal (today called 1st genital) (3-6), latency (6-puberty), and mature genital (puberty-onward). His early formulation included the idea that because of societal restrictions, sexual wishes were repressed into an unconscious state, and that the energy of these unconscious wishes could be turned into anxiety or physical symptoms. Therefore the early treatment techniques, including hypnotism and abreaction, were designed to make the unconscious conscious in order to relieve the pressure and the apparently resulting symptoms.
In On Narcissism (1915)[8] Freud turned his attention to the subject of narcissism. Still utilizing an energic system, Freud conceptualized the question of energy directed at the self versus energy directed at others, called cathexis. By 1917, In "Mourning and Melancholia," he suggested that certain depressions were caused by turning guilt-ridden anger on the self.[9] In 1919 in "A Child is Being Beaten" he began to address the problems of self-destructive behavior (moral masochism) and frank sexual masochism.[10] Based on his experience with depressed and self-destructive patients, and pondering the carnage of WW I, Freud became dissatisfied with considering only oral and sexual motivations for behavior. By 1920, Freud addressed the power of identification (with the leader and with other members) in groups as a motivation for behavior (Group Psychology and Analysis of the Ego).[11] In that same year (1920) Freud suggested his "dual drive" theory of sexuality and aggression in Beyond the Pleasure Principle, to try to begin to explain human destructiveness.[12]
In 1923, he presented his new "structural theory" of an id, ego, and superego in a book entitled, The Ego and the Id.[13] Therein, he revised the whole theory of mental functioning, now considering that repression was only one of many defense mechanisms, and that it occurred to reduce anxiety. Note the 180 degree shift - earlier he had thought that repression caused anxiety. Moreover, in 1926, in Inhibitions, Symptoms and Anxiety, Freud laid out how intrapsychic conflict among drive and superego (wishes and guilt) caused anxiety, and how that anxiety could lead to an inhibition of mental functions, such as intellect and speech.[14]. Inhibitions, Symptoms and Anxiety was written in response to Otto Rank, who, in 1924, published Das Trauma der Geburt (translated into English in 1929 as The Trauma of Birth), exploring how art, myth, religion, philosophy and therapy were illuminated by separation anxiety in the “phase before the development of the Oedipus complex” (p. 216). But there was no such phase in Freud’s theories. The Oedipus complex, Freud explained tirelessly, was the nucleus of the neurosis and the foundational source of all art, myth, religion, philosophy, therapy – indeed of all human culture and civilization. It was the first time that anyone in the inner circle had dared to suggest that the Oedipus complex might not be the only factor contributing to intrapsychic development
By 1936, the "Principle of Multiple Function" was clarified by Robert Waelder.[15] He widened the formulation that psychological symptoms were caused by and relieved conflict simultaneously. Moreover, symptoms (such as phobias and compulsions) each represented elements of some drive wish (sexual and/or aggressive), superego (guilt), anxiety, reality, and defenses. Also in 1936, Anna Freud, Sigmund's famous daughter, published her seminal book, The Ego and the Mechanisms of Defense, outlining numerous ways the mind could shut upsetting things out of consciousness.[16]
1940s-2000s
Following the death of Freud, a new group of psychoanalysts began to explore the function of the ego. Led by Hartmann, Kris, Rappaport and Lowenstein, the group made new discoveries in understanding the synthetic function of the ego as a mediator in psychic functioning. Hartmann in particular distinguished between autonomous ego functions (such as memory and intellect which could be secondarily affected by conflict) and synthetic functions which were a result of compromise formation. These "Ego Psychologists" of the 50's paved a way to focus analytic work by attending to the defenses (mediated by the ego) before exploring the deeper roots to the unconscious conflicts. In addition there was burgeoning interest in child psychoanalysis. Although criticized since its inception, psychoanalysis has been used as a research tool into childhood development,[17] and has developed into a flexible, effective treatment for certain mental disturbances.[18] In the 1960s, Freud's early thoughts on the childhood development of female sexuality were challenged; this challenge led to the development of a variety of understandings of female sexual development, many of which modified the timing and normality of several of Freud's theories (which had been gleaned from the treatment of women with mental disturbances). Several researchers,[19] followed Karen Horney's studies of societal pressures that influence the development of women. Most contemporary North American psychoanalysts employ theories that, while based on those of Sigmund Freud, include many modifications of theory and practice developed since his death in 1939.
In the 2000s there are approximately 35 training institutes for psychoanalysis in the United States accredited by the American Psychoanalytic Association [1][20] which is a component organization of the International Psychoanalytical Association, and there are over 3,000 graduated psychoanalysts practicing in the United States. The International Psychoanalytical Association accredits psychoanalytic training centers throughout the rest of the world, including countries such as Serbia, France, Germany, Austria, Italy, Switzerland, and many others, as well as about six institutes directly in the U.S. Freud published a paper entitled The History of the Psychoanalytic Movement in 1914, German original being first published in the Jahrbuch der Psychoanalyse.[21]
Theories
The predominant psychoanalytic theories can be grouped into several theoretical "schools." Although these theoretical "schools" differ, most of them continue to stress the strong influence of unconscious elements affecting people's mental lives. There has also been considerable work done on consolidating elements of conflicting theory (cf. the work of Theodore Dorpat, B. Killingmo, and S. Akhtar). As in all fields of healthcare, there are some persistent conflicts regarding specific causes of some syndromes, and disputes regarding the best treatment techniques. In the 2000s, psychoanalytic ideas are embedded in Western culture, especially in fields such as childcare, education, literary criticism, cultural studies, and mental health, particularly psychotherapy. Though there is a mainstream of evolved analytic ideas, there are groups who follow the precepts of one or more of the later theoreticians. Psychoanalytic ideas also play roles in some types of literary analysis such as Archetypal literary criticism.
Topographic theory
Topographic theory was first described by Freud in "The Interpretation of Dreams" (1900)[22][23] The theory posits that the mental apparatus can be divided in to the systems Conscious, Pre-conscious and Unconscious. These systems are not anatomical structures of the brain but, rather, mental processes. Although Freud retained this theory throughout his life he largely replaced it with the Structural theory. The Topographic theory remains as one of the metapsychological points of view for describing how the mind functions in classical psychoanalytic theory.
Structural Theory
Structural theory breaks the mind up into the id, the ego, and the superego. Actually, in German, the word for id is "es", which means "it." The word ego was coined by Freud's translators; Freud used the term, "ich" meaning "I" in English. Freud called the superego the "Über-ich". The id was designated as the repository of sexual and aggressive wishes, which Freud called "Triebe" ("drives"). The ego was composed of those forces that opposed the drives – defensive operations. The superego was Freud's term for the conscience – values and ideals, shame and guilt. One problem Brenner (2006) later found with this theory (see above) was that Freud also suggested that forgotten thoughts ("the repressed") were also "located" in the id. However, Freud here realized that drives could be conscious or unconscious, and that consciousness vs. unconsciousness was a quality of any mental operation or any mental conflict. Forgetting things could be done on purpose, or not. People could be aware of guilt, or not.
Ego psychology
Ego psychology was initially suggested by Freud in Inhibitions, Symptoms and Anxiety (1926). The theory was refined by Hartmann, Loewenstein, and Kris in a series of papers and books from 1939 through the late 1960s. Leo Bellak was a later contributor. This series of constructs, paralleling some of the later developments of cognitive theory, includes the notions of autonomous ego functions: mental functions not dependent, at least in origin, on intrapsychic conflict. Such functions include: sensory perception, motor control, symbolic thought, logical thought, speech, abstraction, integration (synthesis), orientation, concentration, judgment about danger, reality testing, adaptive ability, executive decision-making, hygiene, and self-preservation. Freud noted that inhibition is one method that the mind may utilize to interfere with any of these functions in order to avoid painful emotions. Hartmann (1950s) pointed out that there may be delays or deficits in such functions.
Frosch (1964) described differences in those people who demonstrated damage to their relationship to reality, but who seemed able to test it. Deficits in the capacity to organize thought are sometimes referred to as blocking or loose associations (Bleuler), and are characteristic of the schizophrenias. Deficits in abstraction ability and self-preservation also suggest psychosis in adults. Deficits in orientation and sensorium are often indicative of a medical illness affecting the brain (and therefore, autonomous ego functions). Deficits in certain ego functions are routinely found in severely sexually or physically abused children, where powerful affects generated throughout childhood seem to have eroded some functional development.
Ego strengths, later described by Kernberg (1975), include the capacities to control oral, sexual, and destructive impulses; to tolerate painful affects without falling apart; and to prevent the eruption into consciousness of bizarre symbolic fantasy. Synthetic functions, in contrast to autonomous functions, arise from the development of the ego and serve the purpose of managing conflictual processes. Defenses are an example of synthetic functions and serve the purpose of protecting the conscious mind from awareness of forbidden impulses and thoughts. One purpose of ego psychology has been to emphasize that there are mental functions that can be considered to be basic, and not the derivatives of wishes, affects, or defenses. However, it is important to note that autonomous ego functions can be secondarily affected because of unconscious conflict. For example, a patient may have an hysterical amnesia (memory being an autonomous function) because of intrapsychic conflict (wishing not to remember because it is too painful).
Taken together, the above theories present a group of Metapsychological Assumptions. Therefore, the inclusive group of the different classical theories provides a cross-sectional view of human mentation. There are six "points of view", five of which were described by Freud and a sixth added by Hartmann. Unconscious processes can therefore be evaluated from each of these six points of view. The "points of view are" are: 1. Topographic 2. Dynamic (the theory of conflict) 3. Economic (the theory of energy flow) 4. Structural 5. Genetic (propositions concerning origin and development of psychological functions) and 6. Adaptational (psychological phenomena as it relates to the external world).[24]
Conflict Theory
Conflict theory is an update and revision of structural theory that does away with some of the more arcane features of structural theory (such as where repressed thoughts are stored). Conflict theory looks at how emotional symptoms and character traits are complex solutions to mental conflict. [25] This revision of Freud's structural theory (Freud, 1923, 1926) dispenses with the concepts of a fixed id, ego and superego, and instead posits unconscious and conscious conflict among wishes (dependent, controlling, sexual, and aggressive), guilt and shame, emotions (especially anxiety and depressive affect), and defensive operations that shut off from consciousness some aspect of the others. Moreover, healthy functioning (adaptive) is also determined, to a great extent, by resolutions of conflict.
A major goal of modern conflict theorist analysts is to attempt to change the balance of conflict through making aspects of the less adaptive solutions (also called compromise formations) conscious so that they can be rethought, and more adaptive solutions found. Current theoreticians following Brenner's many suggestions (see especially Brenner's 1982 book, "The Mind in Conflict") include Sandor Abend, MD (Abend, Porder, & Willick, (1983), Borderline Patients: Clinical Perspectives), Jacob Arlow (Arlow and Brenner (1964), Psychoanalytic Concepts and the Structural Theory), and Jerome Blackman (2003), 101 Defenses: How the Mind Shields Itself).
Object relations theory
Object relations theory attempts to explain vicissitudes of human relationships through a study of how internal representations of self and of others are structured. The clinical problems that suggest object relations problems (usually developmental delays throughout life) include disturbances in an individual's capacity to feel warmth, empathy, trust, sense of security, identity stability, consistent emotional closeness, and stability in relationships with chosen other human beings. (It is not suggested that one should trust everyone, for example). Concepts regarding internal representations (also sometimes termed, "introjects," "self and object representations," or "internalizations of self and other") although often attributed to Melanie Klein, were actually first mentioned by Sigmund Freud in his early concepts of drive theory (1905, Three Essays on the Theory of Sexuality). Freud's 1917 paper "Mourning and Melancholia", for example, hypothesized that unresolved grief was caused by the survivor's internalized image of the deceased becoming fused with that of the survivor, and then the survivor shifting unacceptable anger toward the deceased onto the now complex self image.
Vamik Volkan, in "Linking Objects and Linking Phenomena," expanded on Freud's thoughts on this, describing the syndromes of "Established pathological mourning" vs. "reactive depression" based on similar dynamics. Melanie Klein's hypotheses regarding internalizations during the first year of life, leading to paranoid and depressive positions, were later challenged by Rene Spitz (e.g., The First Year of Life, 1965), who divided the first year of life into a coenesthetic phase of the first six months, and then a diacritic phase for the second six months. Margaret Mahler (Mahler, Fine, and Bergman (1975), "The Psychological Birth of the Human Infant") and her group, first in New York, then in Philadelphia, described distinct phases and subphases of child development leading to "separation-individuation" during the first three years of life, stressing the importance of constancy of parental figures, in the face of the child's destructive aggression, to the child's internalizations, stability of affect management, and ability to develop healthy autonomy.
Later developers of the theory of self and object constancy as it affects adult psychiatric problems such as psychosis and borderline states have been John Frosch, Otto Kernberg, and Salman Akhtar. Peter Blos described (1960, in a book called On Adolescence) how similar separation-individuation struggles occur during adolescence, of course with a different outcome from the first three years of life: the teen usually, eventually, leaves the parents' house (this varies with the culture). During adolescence, Erik Erikson (1950–1960s) described the "identity crisis," that involves identity-diffusion anxiety. In order for an adult to be able to experience "Warm-ETHICS" (warmth, empathy, trust, holding environment (Winnicott), identity, closeness, and stability) in relationships (see Blackman (2003), 101 Defenses: How the Mind Shields Itself), the teenager must resolve the problems with identity and redevelop self and object constancy.
Self psychology
Self psychology emphasizes the development of a stable and integrated sense of self through empathic contacts with other humans, primary significant others conceived of as "selfobjects." Selfobjects meet the developing self's needs for mirroring, idealization, and twinship, and thereby strengthen the developing self. The process of treatment proceeds through "transmuting internalizations" in which the pt gradually internalizes the selfobject functions provided by the therapist. Self psychology was proposed originally by Heinz Kohut, and has been further developed by Arnold Goldberg, Frank Lachmann, Paul and Anna Ornstein, Marian Tolpin, and others.
Jacques Lacan/Lacanian psychoanalysis
Lacanian psychoanalysis integrates psychoanalysis with semiotics and Hegelian philosophy, and is practiced throughout the world. It is especially popular in France and Latin America. Lacanian psychoanalysis is a departure from the traditional British and American psychoanalysis, which is predominantly Ego psychology. Lacan frequently used the phrase "retourner à Freud" in his seminars and writings meaning "back to Freud" as he claimed that his theories were an extension of Freud's own, contrary to those of Anna Freud, the Ego Psychology, object relations and "self" theories. Lacan's first major contributions concern the "mirror stage", the Real, the Imaginary and the Symbolic, and the claim the "unconscious is structured as a language".
Interpersonal psychoanalysis
Interpersonal psychoanalysis accents the nuances of interpersonal interactions, particularly how individuals protect themselves from anxiety by establishing collusive interactions with others. Interpersonal theory was first introduced by Harry Stack Sullivan, MD, and developed further by Frieda Fromm-Reichmann.
Relational psychoanalysis
Relational psychoanalysis combines interpersonal psychoanalysis with object-relations theory and with Inter-subjective theory as critical for mental health, was introduced by Stephen Mitchell.[26] Relational psychoanalysis emphasizes how the individual's personality is shaped by both real and imagined relationships with others, and how these relationship patterns are re-enacted in the interactions between analyst and patient. Fonagy and Target, in London, have propounded their view of the necessity of helping certain detached, isolated patients, develop the capacity for "mentalization" associated with thinking about relationships and themselves.
Intersubjective psychoanalysis
The term "intersubjectivity" was introduced in psychoanalysis by George E. Atwood and Robert Stolorow (1984). Intersubjective approaches emphasize how both personality development and the therapeutic process are influenced by the interrelationship between the patient's subjective perspective and that of others. The authors of the relational and intersubjective approaches: Otto Rank, Heinz Kohut, Stephen A. Mitchell, Jessica Benjamin, Bernard Brandchaft, J. Fosshage, Donna M.Orange, Arnold Modell, Thomas Ogden, Owen Renik, Harold Searles, Colwyn Trewarthen, Edgar A. Levenson, J. R. Greenberg, Edward R. Ritvo, Beatrice Beebe, Frank M. Lachmann, Herbert Rosenfeld and Daniel Stern.
Modern psychoanalysis
"Modern psychoanalysis" is a term coined by Hyman Spotnitz and his colleagues to describe a body of theoretical and clinical work undertaken from the 1950s onwards, with the aim of extending Freud's theories so as to make them applicable to the full spectrum of emotional disorders. Interventions based on this approach are primarily intended to provide an emotional-maturational communication to the patient, rather than to promote intellectual insight.
Psychopathology (mental disturbances)
Adult patients
The various psychoses involve deficits in the autonomous ego functions (see above) of integration (organization) of thought, in abstraction ability, in relationship to reality and in reality testing. In depressions with psychotic features, the self-preservation function may also be damaged (sometimes by overwhelming depressive affect). Because of the integrative deficits (often causing what general psychiatrists call "loose associations," "blocking," "flight of ideas," "verbigeration," and "thought withdrawal"), the development of self and object representations is also impaired. Clinically, therefore, psychotic individuals manifest limitations in warmth, empathy, trust, identity, closeness and/or stability in relationships (due to problems with self-object fusion anxiety) as well.
In patients whose autonomous ego functions are more intact, but who still show problems with object relations, the diagnosis often falls into the category known as "borderline." Borderline patients also show deficits, often in controlling impulses, affects, or fantasies – but their ability to test reality remains more or less intact. Adults who do not experience guilt and shame, and who indulge in criminal behavior, are usually diagnosed as psychopaths, or, using DSM-IV-TR, antisocial personality disorder.
Panic, phobias, conversions, obsessions, compulsions and depressions (analysts call these "neurotic symptoms") are not usually caused by deficits in functions. Instead, they are caused by intrapsychic conflicts. The conflicts are generally among sexual and hostile-aggressive wishes, guilt and shame, and reality factors. The conflicts may be conscious or unconscious, but create anxiety, depressive affect, and anger. Finally, the various elements are managed by defensive operations – essentially shut-off brain mechanisms that make people unaware of that element of conflict. "Repression" is the term given to the mechanism that shuts thoughts out of consciousness. "Isolation of affect" is the term used for the mechanism that shuts sensations out of consciousness. Neurotic symptoms may occur with or without deficits in ego functions, object relations, and ego strengths. Therefore, it is not uncommon to encounter obsessive-compulsive schizophrenics, panic patients who also suffer with borderline personality disorder, etc.
Childhood origins
Freudian theories point out that adult problems can be traced to unresolved conflicts from certain phases of childhood and adolescence. Freud, based on the data gathered from his patients early in his career, suspected that neurotic disturbances occurred when children were sexually abused in childhood (the so-called seduction theory). Later, Freud came to realize that, although child abuse occurs, that not all neurotic symptoms were associated with this. He realized that neurotic people often had unconscious conflicts that involved incestuous fantasies deriving from different stages of development. He found the stage from about three to six years of age (preschool years, today called the "first genital stage") to be filled with fantasies of having romantic relationships with both parents. Although arguments were generated in early 20th-century Vienna about whether adult seduction of children was the basis of neurotic illness, there is virtually no argument about this problem in the 21st century.
Many psychoanalysts who work with children have studied the actual effects of child abuse, which include ego and object relations deficits and severe neurotic conflicts. Much research has been done on these types of trauma in childhood, and the adult sequelae of those. On the other hand, many adults with symptom neuroses and character pathology have no history of childhood sexual or physical abuse. In studying the childhood factors that start neurotic symptom development, Freud found a constellation of factors that, for literary reasons, he termed the Oedipus complex (based on the play by Sophocles, Oedipus Rex, where the protagonist unwittingly kills his father Laius and marries his mother Jocasta). The shorthand term, "oedipal," (later explicated by Joseph Sandler in "On the Concept Superego" (1960) and modified by Charles Brenner in "The Mind in Conflict" (1982)) refers to the powerful attachments that children make to their parents in the preschool years. These attachments involve fantasies of sexual relationships with either (or both) parent, and, therefore, competitive fantasies toward either (or both) parents. Humberto Nagera (1975) has been particularly helpful in clarifying many of the complexities of the child through these years.
The terms "positive" and "negative" oedipal conflicts have been attached to the heterosexual and homosexual aspects, respectively. Both seem to occur in development of most children. Eventually, the developing child's concessions to reality (that they will neither marry one parent nor eliminate the other) lead to identifications with parental values. These identifications generally create a new set of mental operations regarding values and guilt, subsumed under the term "superego." Besides superego development, children "resolve" their preschool oedipal conflicts through channeling wishes into something their parents approve of ("sublimations") and the development, during the school-age years ("latency") of age-appropriate obsessive-compulsive defensive maneuvers (rules, repetitive games).
Treatment
Using the various analytic theories to assess mental problems, several particular constellations of problems are particularly suited for analytic techniques (see below) whereas other problems respond better to medicines and different interpersonal interventions. To be treated with psychoanalysis, whatever the presenting problem, the person requesting help must demonstrate a desire to start an analysis. The person wishing to start an analysis must have some capacity for speech and communication. As well, they need to be able to have trust and empathy within the psychoanalytic session. Potential patients must undergo a preliminary stage of treatment to assess their amenability to psychoanalysis, at that time, and also to enable the analyst to form a working psychological model which the analyst will use to direct the treatment. Psychoanalysts mainly work with neurosis and hysteria in particular however adapted forms of psychoanalysis are used in working with schizophrenia and other forms of psychosis. Finally, if a prospective patient is severely suicidal a longer preliminary stage may be employed, sometimes with sessions which have a twenty minute break in the middle. There are modifications of techniques due to the radically individualistic nature of each persons analysis.
The most common problems treatable with psychoanalysis include: phobias, conversions, compulsions, obsessions, anxiety attacks, depressions, sexual dysfunctions, a wide variety of relationship problems (such as dating and marital strife), and a wide variety of character problems (for example, painful shyness, meanness, obnoxiousness, workaholism, hyperseductiveness, hyperemotionality, hyperfastidiousness). The fact that many of such patients also demonstrate deficits above makes diagnosis and treatment selection difficult.
Analytical organizations such as the International Psychoanalytic Association,[27] The American Psychoanalytic Association,[28] and the European Federation for Psychoanalytic Psychotherapy,[29] have established procedures and models for the indication and practice of psychoanalytical therapy for trainees in analysis. The match between the analyst and the patient can be viewed as another contributing factor for the indication and contraindication for psychoanalytic treatment. The analyst decides whether the patient is suitable for psychoanalysis. This decision made by the analyst, besides made on the usual indications and pathology, is also based to a certain degree by the "fit" between analyst and patient. A persons suitability for analysis at any particular time is based around their desire to know something about where their illness has come from. Someone who is not suitable for analysis expresses no desire to know more about the root causes of their illness. An evaluation may include one or more other analysts' independent opinions and will include discussion of the patient's financial situation and insurances.
Techniques
The basic method of psychoanalysis is interpretation of the patient's unconscious conflicts that are interfering with current-day functioning – conflicts that are causing painful symptoms such as phobias, anxiety, depression, and compulsions. Strachey (1936) stressed that figuring out ways the patient distorted perceptions about the analyst led to understanding what may have been forgotten (also see Freud's paper "Repeating, Remembering, and Working Through"). In particular, unconscious hostile feelings toward the analyst could be found in symbolic, negative reactions to what Robert Langs later called the "frame" of the therapy – the setup that included times of the sessions, payment of fees, and necessity of talking. In patients who made mistakes, forgot, or showed other peculiarities regarding time, fees, and talking, the analyst can usually find various unconscious "resistances" to the flow of thoughts (sometimes called free association).
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Freud's patients would lie on this couch during psychoanalysis
When the patient reclines on a couch with the analyst out of view, the patient tends to remember more, experience more resistance and transference, and be able to reorganize thoughts after the development of insight – through the interpretive work of the analyst. Although fantasy life can be understood through the examination of dreams, masturbation fantasies (cf. Marcus, I. and Francis, J. (1975), Masturbation from Infancy to Senescence) are also important. The analyst is interested in how the patient reacts to and avoids such fantasies (cf. Paul Gray (1994), The Ego and the Analysis of Defense).[30] Various memories of early life are generally distorted – Freud called them "screen memories" – and in any case, very early experiences (before age two) – can not be remembered (See the child studies of Eleanor Galenson on "evocative memory").
Variations in technique
There is what is known among psychoanalysts as "classical technique," although Freud throughout his writings deviated from this considerably, depending on the problems of any given patient. Classical technique was summarized by Allan Compton, MD, as comprising instructions (telling the patient to try to say what's on their mind, including interferences); exploration (asking questions); and clarification (rephrasing and summarizing what the patient has been describing). As well, the analyst can also use confrontation to bringing an aspect of functioning, usually a defense, to the patient's attention. The analyst then uses a variety of interpretation methods, such as dynamic interpretation (explaining how being too nice guards against guilt, e.g. - defense vs. affect); genetic interpretation (explaining how a past event is influencing the present); resistance interpretation (showing the patient how they are avoiding their problems); transference interpretation (showing the patient ways old conflicts arise in current relationships, including that with the analyst); or dream interpretation (obtaining the patient's thoughts about their dreams and connecting this with their current problems). Analysts can also use reconstruction to estimate what may have happened in the past that created some current issue.
These techniques are primarily based on conflict theory (see above). As object relations theory evolved, grass supplemented by the work of Bowlby, Ainsorth, and Beebe, techniques with patients who had more severe problems with basic trust (Erikson, 1950) and a history of maternal deprivation (see the works of Augusta Alpert) led to new techniques with adults. These have sometimes been called interpersonal, intersubjective (cf. Stolorow), relational, or corrective object relations techniques. These techniques include expressing an empathic attunement to the patient or warmth; exposing a bit of the analyst's personal life or attitudes to the patient; allowing the patient autonomy in the form of disagreement with the analyst (cf. I.H. Paul, Letters to Simon.); and explaining the motivations of others which the patient misperceives. Ego psychological concepts of deficit in functioning led to refinements in supportive therapy. These techniques are particularly applicable to psychotic and near-psychotic (cf., Eric Marcus, "Psychosis and Near-psychosis") patients. These supportive therapy techniques include discussions of reality; encouragement to stay alive (including hospitalization); psychotropic medicines to relieve overwhelming depressive affect or overwhelming fantasies (hallucinations and delusions); and advice about the meanings of things (to counter abstraction failures).
The notion of the "silent analyst" has been criticized. Actually, the analyst listens using Arlow's approach as set out in "The Genesis of Interpretation"), using active intervention to interpret resistances, defenses creating pathology, and fantasies. Silence and non-responsiveness was a technique promulgated by Carl Rogers, in his development of so-called "Client Centered Therapy" – and is not a technique of psychoanalysis (also see the studies and opinion papers of Owen Renik, MD). "Analytic Neutrality" is a concept that does not mean the analyst is silent. It refers to the analyst's position of not taking sides in the internal struggles of the patient. For example, if a patient feels guilty, the analyst might explore what the patient has been doing or thinking that causes the guilt, but not reassure the patient not to feel guilty. The analyst might also explore the identifications with parents and others that led to the guilt.
Group therapy and play therapy
Although single-client sessions remain the norm, psychoanalytic theory has been used to develop other types of psychological treatment. Psychoanalytic group therapy was pioneered by Trigant Burrow, Joseph Pratt, Paul F. Schilder, Samuel R. Slavson, Harry Stack Sullivan, and Wolfe. Child-centered counseling for parents was instituted early in analytic history by Freud, and was later further developed by Irwin Marcus, Edith Schulhofer, and Gilbert Kliman. Psychoanalytically based couples therapy has been promulgated and explicated by Fred Sander, MD. Techniques and tools developed in the 2000s have made psychoanalysis available to patients who were not treatable by earlier techniques. This meant that the analytic situation was modified so that it would be more suitable and more likely to be helpful for these patients. M.N. Eagle (2007) believes that psychoanalysis cannot be a self-contained discipline but instead must be open to influence from and integration with findings and theory from other disciplines.[31]
Psychoanalytic constructs have been adapted for use with children with treatments such as play therapy, art therapy, and storytelling. Throughout her career, from the 1920s through the 1970s, Anna Freud adapted psychoanalysis for children through play. This is still used today for children, especially those who are preadolescent (see Leon Hoffman, New York Psychoanalytic Institute Center for Children). Using toys and games, children are able to demonstrate, symbolically, their fears, fantasies, and defenses; although not identical, this technique, in children, is analogous to the aim of free association in adults. Psychoanalytic play therapy allows the child and analyst to understand children's conflicts, particularly defenses such as disobedience and withdrawal, that have been guarding against various unpleasant feelings and hostile wishes. In art therapy, the counselor may have a child draw a portrait and then tell a story about the portrait. The counselor watches for recurring themes—regardless of whether it is with art or toys.
Cultural variations
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 wherever 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 a therapist to help clients develop a cultural identity as well as an ego identity.
Cost and length of treatment
The cost to the patient of psychoanalytic treatment ranges widely from place to place and between practitioners. Low-fee analysis is often available in a psychoanalytic training clinic and graduate schools. Otherwise, the fee set by each analyst varies with the analyst's training and experience. Since, in most locations in the United States, unlike in Ontario and Germany, classical analysis (which usually requires sessions three to five times per week) is not covered by health insurance, many analysts may negotiate their fees with patients whom they feel they can help, but who have financial difficulties. The modifications of analysis, which include dynamic therapy, brief therapies, and certain types of group therapy (cf. Slavson, S. R., A Textbook in Analytic Group Therapy), are carried out on a less frequent basis - usually once, twice, or three times a week - and usually the patient sits facing the therapist.
Many studies have also been done on briefer "dynamic" treatments; these are more expedient to measure, and shed light on the therapeutic process to some extent. Brief Relational Therapy (BRT), Brief Psychodynamic Therapy (BPT), and Time-Limited Dynamic Therapy (TLDP) limit treatment to 20-30 sessions. On average, classical analysis may last 5.7 years, but for phobias and depressions uncomplicated by ego deficits or object relations deficits, analysis may run for a shorter period of time. Longer analyses are indicated for those with more serious disturbances in object relations, more symptoms, and more ingrained character pathology (such as obnoxiousness, severe passivity, or heinous procrastination).
Training and research
Psychoanalytic training in the United States, in most locations, involves personal analytic treatment for the trainee, conducted confidentially, with no report to the Education Committee of the Analytic Training Institute; approximately 600 hours of class instruction, with a standard curriculum, over a four-year period. Classes are often a few hours per week, or for a full day or two every other weekend during the academic year; this varies with the institute; and supervision once per week, with a senior analyst, on each analytic treatment case the trainee has. The minimum number of cases varies between institutes, often two to four cases. Male and female cases are required. Supervision must go on for at least a few years on one or more cases. Supervision is done in the supervisor's office, where the trainee presents material from the analytic work that week, examines the unconscious conflicts with the supervisor, and learns, discusses, and is advised about technique.
Psychoanalytic Training Centers in the United States have been accredited by special committees of the
See also