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Psychoanalysis is a set of theories and therapeutic techniques related to the study of the unconscious mind, which together form a method of treatment for mental-health disorders. The discipline was established in the early 1890s by Austrian neurologist Sigmund Freud and stemmed partly from the clinical work of Josef Breuer and others. Psychoanalysis was later developed in different directions, mostly by students of Freud such as Alfred Adler and Carl Gustav Jung, and by neo-Freudians such as Erich Fromm, Karen Horney and Harry Stack Sullivan. Freud retained the term psychoanalysis for his own school of thought.
Psychoanalysis is a controversial discipline and its validity as a science is contested. Nonetheless, it remains a strong influence within psychiatry, more so in some quarters than others. The proportion of practitioners of Freudian psychoanalysis has declined as evidence-based medicine has increased the use of cognitive behavioral therapy. Psychoanalytic concepts are also widely used outside the therapeutic arena, in areas such as psychoanalytic literary criticism, as well as in the analysis of film, fairy tales and other cultural phenomena.
Psychoanalysis is a set of theories and therapeutic techniques related to the study of the unconscious mind, which together form a method of treatment for mental-health disorders. The discipline was established in the early 1890s by Austrian neurologist Sigmund Freud and stemmed partly from the clinical work of Josef Breuer and others. Psychoanalysis was later developed in different directions, mostly by students of Freud such as Alfred Adler and Carl Gustav Jung, and by neo-Freudians such as Erich Fromm, Karen Horney and Harry Stack Sullivan. Freud retained the term psychoanalysis for his own school of thought.
Psychoanalysis is a controversial discipline and its validity as a science is contested. Nonetheless, it remains a strong influence within psychiatry, more so in some quarters than others. The proportion of practitioners of Freudian psychoanalysis has declined as evidence-based medicine has increased the use of cognitive behavioral therapy. Psychoanalytic concepts are also widely used outside the therapeutic arena, in areas such as psychoanalytic literary criticism, as well as in the analysis of film, fairy tales and other cultural phenomena.
The basic tenets of psychoanalysis include:
- a person's development is determined by often forgotten events in early childhood, rather than by inherited traits alone;
- human behaviour and cognition are largely determined by instinctual drives that are rooted in the unconscious;
- attempts to bring those drives into awareness triggers resistance in the form of defense mechanisms, particularly repression;
- conflicts between conscious and unconscious material can result in mental disturbances such as neurosis, neurotic traits, anxiety and depression;
- unconscious material can be found in dreams and unintentional acts, including mannerisms and slips of the tongue;
- liberation from the effects of the unconscious is achieved by bringing this material into the conscious mind through therapeutic intervention;
- the "centerpiece of the psychoanalytic process" is the transference, whereby patients relive their infantile conflicts by projecting onto the analyst feelings of love, dependence and anger.
Practice
During psychoanalytic sessions, which typically last 50 minutes and ideally take place 4–5 times a week,
the patient (the "analysand") may lie on a couch, with the analyst
often sitting just behind and out of sight. The patient expresses his or
her thoughts, including free associations, fantasies
and dreams, from which the analyst infers the unconscious conflicts
causing the patient's symptoms and character problems. Through the
analysis of these conflicts, which includes interpreting the
transference and countertransference (the analyst's feelings for the patient), the analyst confronts the patient's pathological defenses to help the patient gain insight.
History
Freud first used the term psychoanalysis (in French) in 1896. Die Traumdeutung (The Interpretation of Dreams), which Freud saw as his "most significant work", appeared in November 1899. Psychoanalysis was later developed in different directions, mostly by students of Freud such as Alfred Adler and Carl Gustav Jung, and by neo-Freudians such as Erich Fromm, Karen Horney and Harry Stack Sullivan. Freud retained the term psychoanalysis for his own school of thought.
1890s
The idea of psychoanalysis (German: Psychoanalyse)
first started to receive serious attention under Sigmund Freud, who
formulated his own theory of psychoanalysis in Vienna in the 1890s.
Freud was a neurologist trying to find an effective treatment for patients with neurotic or hysterical
symptoms. Freud realised that there were mental processes that were not
conscious, whilst he was employed as a neurological consultant at the
Children's Hospital, where he noticed that many aphasic children had no apparent organic cause for their symptoms. He then wrote a monograph about this subject. In 1885, Freud obtained a grant to study with Jean-Martin Charcot, a famed neurologist, at the Salpêtrière
in Paris, where Freud followed the clinical presentations of Charcot,
particularly in the areas of hysteria, paralyses and the anaesthesias.
Charcot had introduced hypnotism as an experimental research tool and
developed the photographic representation of clinical symptoms.
Freud's first theory to explain hysterical symptoms was presented in Studies on Hysteria (1895), co-authored with his mentor the distinguished physician Josef Breuer, which was generally seen as the birth of psychoanalysis. The work was based on Breuer's treatment of Bertha Pappenheim, referred to in case studies by the pseudonym "Anna O.", treatment which Pappenheim herself had dubbed the "talking cure".
Breuer wrote that many factors that could result in such symptoms,
including various types of emotional trauma, and he also credited work
by others such as Pierre Janet;
while Freud contended that at the root of hysterical symptoms were
repressed memories of distressing occurrences, almost always having
direct or indirect sexual associations.
Around the same time Freud attempted to develop a
neuro-physiological theory of unconscious mental mechanisms, which he
soon gave up. It remained unpublished in his lifetime.
The first occurrence of the term "psychoanalysis" (written psychoanalyse) was in Freud's essay "L'hérédité et l’étiologie des névroses" which was written and published in French in 1896.
In 1896 Freud also published his so-called seduction theory
which proposed that the preconditions for hysterical symptoms are
sexual excitations in infancy, and he claimed to have uncovered
repressed memories of incidents of sexual abuse for all his current
patients. However, by 1898 he had privately acknowledged to his friend and colleague Wilhelm Fliess that he no longer believed in his theory, though he did not state this publicly until 1906.
Though in 1896 he had reported that his patients "had no feeling of
remembering the [infantile sexual] scenes", and assured him
"emphatically of their unbelief",
in later accounts he claimed that they had told him that they had been
sexually abused in infancy. This became the received historical account
until challenged by several Freud scholars in the latter part of the
20th century who argued that he had imposed his preconceived notions on
his patients.
However, building on his claims that the patients reported infantile
sexual abuse experiences, Freud subsequently contended that his clinical
findings in the mid-1890s provided evidence of the occurrence of
unconscious fantasies, supposedly to cover up memories of infantile masturbation. Only much later did he claim the same findings as evidence for Oedipal desires.
By 1899, Freud had theorised that dreams had symbolic
significance, and generally were specific to the dreamer. Freud
formulated his second psychological theory— which hypothesises that the
unconscious has or is a "primary process" consisting of symbolic and
condensed thoughts, and a "secondary process" of logical, conscious
thoughts. This theory was published in his 1899 book, The Interpretation of Dreams.
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. This "topographic theory" is still popular
in much of Europe, although it has fallen out of favour in much of North
America.
1900–1940s
In 1905, Freud published Three Essays on the Theory of Sexuality 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. This method would later on be left aside
by Freud, giving free association a bigger role.
In On Narcissism (1915)
Freud turned his attention to the subject of narcissism. Still using an
energic system, Freud characterized the difference between 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.
In 1919 in "A Child is Being Beaten" he began to address the problems
of self-destructive behavior (moral masochism) and frank sexual
masochism. Based on his experience with depressed and self-destructive patients, and pondering the carnage of World War 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 the Analysis of the Ego). 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. Also, it was the
first appearance of his "structural theory" consisting three new
concepts id, ego, and superego.
Three years later, he summarised the ideas of id, ego, and superego in The Ego and the Id.
In the book, 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. Hence, Freud characterised
repression as both a cause and a result of anxiety. In 1926, in Inhibitions, Symptoms and Anxiety, Freud characterised 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. 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),
analysing how art, myth, religion, philosophy and therapy were
illuminated by separation anxiety in the "phase before the development
of the Oedipus complex".
Freud's theories, however, characterized no such phase. According to
Freud, the Oedipus complex, was at the centre of neurosis, and was 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 characterised something other than the Oedipus complex as
contributing to intrapsychic development, a notion that was rejected by
Freud and his followers at the time.
By 1936 the "Principle of Multiple Function" was clarified by Robert Waelder.
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, anxiety, reality, and defenses. Also in 1936, Anna Freud, Sigmund's daughter, published her seminal book, The Ego and the Mechanisms of Defense, outlining numerous ways the mind could shut upsetting things out of consciousness.
1940s–present
When Hitler's power grew, the Freud family and many of their colleagues fled to London. Within a year, Sigmund Freud died.
In the United States, also following the death of Freud, a new group
of psychoanalysts began to explore the function of the ego. Led by Heinz Hartmann,
Kris, Rappaport and Lowenstein, the group built upon understandings of
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 1950s 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, and is still used to treat certain mental disturbances. 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 followed Karen Horney's studies of societal pressures that influence the development of women.
In the first decade of the 21st century, there were approximately
35 training institutes for psychoanalysis in the United States
accredited by the American Psychoanalytic Association (APsaA), which is a component organization of the International Psychoanalytical Association
(IPA), and there are over 3000 graduated psychoanalysts practicing in
the United States. The IPA accredits psychoanalytic training centers
through such "component organisations" 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 United States.
Theories
The
predominant psychoanalytic theories can be organised into several
theoretical schools. Although these theoretical schools differ, most of
them emphasize the influence of unconscious elements on the conscious.
There has also been considerable work done on consolidating elements of
conflicting theories (cf. the work of Theodore Dorpat, B. Killingmo, and
S. Akhtar). As in all fields of medicine,
there are some persistent conflicts regarding specific causes of
certain syndromes, and disputes regarding the ideal treatment
techniques. In the 21st century, psychoanalytic ideas are embedded in
Western culture, especially in fields such as childcare, education, literary criticism, cultural studies, mental health, and 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 named and first described by Sigmund Freud in The Interpretation of Dreams (1899).
The theory hypothesizes that the mental apparatus can be divided into
the systems Conscious, Preconscious, 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 meta-psychological points
of view for describing how the mind functions in classical
psychoanalytic theory.
Structural theory
Structural theory divides the psyche into the id, the ego, and the super-ego. The id is present at birth as the repository of basic instincts, which Freud called "Triebe"
("drives"): unorganized and unconscious, it operates merely on the
'pleasure principle', without realism or foresight. The ego develops
slowly and gradually, being concerned with mediating between the urging
of the id and the realities of the external world; it thus operates on
the 'reality principle'. The super-ego is held to be the part of the ego
in which self-observation, self-criticism and other reflective and
judgmental faculties develop. The ego and the super-ego are both partly
conscious and partly unconscious.
Theoretical and Clinical Approaches
During the twentieth century, many different clinical and theoretical models of psychoanalysis emerged.
Ego Psychology
Ego psychology was initially suggested by Freud in Inhibitions, Symptoms and Anxiety (1926). A major step forward was Anna Freud's work on defense mechanisms, first published in her book The Ego and the Mechanisms of Defence (1936).
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.
According to ego psychology, ego strengths, later described by Otto F. 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 conflict
processes. Defenses are synthetic functions that protect the conscious
mind from awareness of forbidden impulses and thoughts. One purpose of
ego psychology has been to emphasize that some mental functions can be
considered to be basic, rather than derivatives of wishes, affects, or
defenses. However, 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 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: 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).
Modern conflict theory
Modern
conflict theory, a variation of ego psychology, is a revised version of
structural theory, most notably different by altering concepts related
to where repressed thoughts were stored(Freud, 1923, 1926). Modern
conflict theory addresses emotional symptoms and character traits as
complex solutions to mental conflict. It dispenses with the concepts of a fixed id, ego and superego,
and instead posits conscious and unconscious 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 objective of modern conflict-theory psychoanalysis is to
change the balance of conflict in a patient by 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 the ups and downs of human relationships through a
study of how internal representations of the self and others are
organized. The clinical symptoms that suggest object relations problems
(typically 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 significant others. (It is not suggested
that one should trust everyone, for example.) Concepts regarding
internal representations (also sometimes termed, "introspects", "self
and object representations", or "internalization of self and other")
although often attributed to Melanie Klein, were actually first mentioned by Sigmund Freud in his early concepts of drive theory (Three Essays on the Theory of Sexuality,
1905). 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 internalization during the first year of
life, leading to paranoid and depressive positions, were later
challenged by René 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, The Psychological Birth of the Human Infant,
1975) 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.
John Frosch, Otto Kernberg, Salman Akhtar and Sheldon Bach
have developed the theory of self and object constancy as it affects
adult psychiatric problems such as psychosis and borderline states.
Peter Blos described (in a book called On Adolescence, 1960) 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, 101 Defenses: How the Mind Shields Itself, 2001), 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 patient 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 and Lacanian psychoanalysis
Lacanian psychoanalysis, which integrates psychoanalysis with structural linguistics and Hegelian
philosophy, is especially popular in France and parts of Latin America.
Lacanian psychoanalysis is a departure from the traditional British and
American psychoanalysis, which is predominantly Ego psychology.
Jacques Lacan frequently used the phrase "retourner à Freud" ("return
to Freud") in his seminars and writings, 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 and also claims the necessity of reading Freud's
complete works, not only a part of them. Lacan's concepts concern the "mirror stage", the "Real", the "Imaginary", and the "Symbolic", and the claim that "the unconscious is structured as a language".
Though a major influence on psychoanalysis in France and parts of
Latin America, Lacan and his ideas have taken longer to be translated
into English and he has thus had a lesser impact on psychoanalysis and
psychotherapy in the English-speaking world. In the United Kingdom and
the United States, his ideas are most widely used to analyze texts in literary theory.
Due to his increasingly critical stance towards the deviation from
Freud's thought, often singling out particular texts and readings from
his colleagues, Lacan was excluded from acting as a training analyst in
the IPA, thus leading him to create his own school in order to maintain
an institutional structure for the many candidates who desired to continue their analysis with him.
Interpersonal psychoanalysis
Interpersonal psychoanalysis
accents the nuances of interpersonal interactions, particularly how
individuals protect themselves from anxiety by establishing collusive
interactions with others, and the relevance of actual experiences with
other persons developmentally (e.g. family and peers) as well as in the
present. This is contrasted with the primacy of intrapsychic forces, as
in classical psychoanalysis. Interpersonal theory was first introduced
by Harry Stack Sullivan, MD, and developed further by Frieda Fromm-Reichmann, Clara Thompson, Erich Fromm, and others who contributed to the founding of the William Alanson White Institute and Interpersonal Psychoanalysis in general.
Culturalist psychoanalysis
Some psychoanalysts have been labeled culturalist, because of the prominence they attributed culture in the genesis of behavior. Among others, Erich Fromm, Karen Horney, Harry Stack Sullivan, have been called culturalist psychoanalysts. They were famously in conflict with orthodox psychoanalysts.
Feminist psychoanalysis
Feminist
theories of psychoanalysis emerged towards the second half of the 20th
century, in an effort to articulate the feminine, the maternal and
sexual difference and development from the point of view of female
subjects. For Freud, male is subject and female is object. For Freud, Winnicott and the object relations theories, the mother is structured as the object of the infant's rejection (Freud) and destruction (Winnicott). For Lacan,
the "woman" can either accept the phallic symbolic as an object or
incarnate a lack in the symbolic dimension that informs the structure of
the human subject. Feminist psychoanalysis is mainly post-Freudian and
post-Lacanian with theorists like Toril Moi, Joan Copjec, Juliet Mitchell, Teresa Brennan and Griselda Pollock, following French feminist psychoanalysis, the gaze and sexual difference in, of and from the feminine. French theorists like Luce Irigaray challenge phallogocentrism. Bracha Ettinger offers a "matrixial" subject's dimension that brings into account the prenatal stage (matrixial connectivity) and suggests a feminine-maternal Eros, matrixial gaze and Primal mother-phantasies. Jessica Benjamin addresses the question of the feminine and love. Feminist psychoanalysis informs and includes gender, queer and post-feminist theories.
Adaptive paradigm of psychoanalysis and psychotherapy
The "adaptive paradigm of psychotherapy" develops out of the work of Robert Langs.
The adaptive paradigm interprets psychic conflict primarily in terms of
conscious and unconscious adaptation to reality. Langs’ recent work in
some measure returns to the earlier Freud, in that Langs prefers a
modified version of the topographic model of the mind (conscious, preconscious, and unconscious) over the structural model
(id, ego, and super-ego), including the former’s emphasis on trauma
(though Langs looks to death-related traumas rather than sexual
traumas).
At the same time, Langs’ model of the mind differs from Freud’s in that
it understands the mind in terms of evolutionary biological principles.
Relational psychoanalysis
Relational psychoanalysis
combines interpersonal psychoanalysis with object-relations theory and
with inter-subjective theory as critical for mental health. It was
introduced by Stephen Mitchell.
Relational psychoanalysis stresses 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. In New York, key proponents of relational
psychoanalysis include Lew Aron, Jessica Benjamin, and Adrienne Harris. 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. Arietta Slade, Susan Coates, and Daniel Schechter
in New York have additionally contributed to the application of
relational psychoanalysis to treatment of the adult patient-as-parent,
the clinical study of mentalization in parent-infant relationships, and
the intergenerational transmission of attachment and trauma.
Interpersonal-relational psychoanalysis
The
term interpersonal-relational psychoanalysis is often used as a
professional identification. Psychoanalysts under this broader umbrella
debate about what precisely are the differences between the two
schools, without any current clear consensus.
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 interpersonal-relational and
intersubjective approaches: Otto Rank, Heinz Kohut, Stephen A. Mitchell, Jessica Benjamin, Bernard Brandchaft, J. Fosshage, Donna M.Orange, Arnold "Arnie" Mindell, Thomas Ogden, Owen Renik, Irwin Z. Hoffman, Harold Searles, Colwyn Trevarthen, Edgar A. Levenson, Jay 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
approaches that aim to extend Freud's theories so as to make them
applicable to the full spectrum of emotional disorders and broaden the
potential for treatment to pathologies thought to be untreatable by
classical methods.
Interventions based on this approach are primarily intended to provide
an emotional-maturational communication to the patient, rather than to
promote intellectual insight. These interventions, beyond insight
directed aims, are used to resolve resistances that are presented in the
clinical setting. This school of psychoanalysis has fostered training
opportunities for students in the United States and from countries
worldwide. Its journal Modern Psychoanalysis has been published since
1976.
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.
This section above is partial to ego psychoanalytic theory
"autonomous ego functions". As the "autonomous ego functions" theory is
only a theory, it may yet be proven incorrect.
Childhood origins
Freudian theories hold that adult problems can be traced to unresolved conflicts from certain phases of childhood and adolescence,
caused by fantasy, stemming from their own drives. 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 believe that, although child abuse occurs,
neurotic symptoms were not associated with this. He believed 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. Arguments were quickly
generated in early 20th-century Vienna about whether adult seduction of
children, i.e. child sexual abuse,
was the basis of neurotic illness. There still is no complete
agreement, although nowadays professionals recognize the negative
effects of child sexual abuse on mental health.
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. 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 validity of the Oedipus complex is now widely disputed and rejected. The shorthand term, "oedipal" — later explicated by Joseph J. 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.
"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 ("sublimation") and the development, during the school-age years
("latency") of age-appropriate obsessive-compulsive defensive maneuvers (rules, repetitive games).
Treatment
Using the various analytic and psychological techniques to assess
mental problems, some believe that there are particular constellations
of problems that are especially suited for analytic treatment (see
below) whereas other problems might respond better to medicines and
other 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 or develop trust and insight 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 or mental disorder.
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 numerous modifications in
technique under the heading of psychoanalysis due to the individualistic
nature of personality in both analyst and patient.
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 IPA, APsaA and the European
Federation for Psychoanalytic Psychotherapy 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 person's suitability for analysis at any particular time is based on
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).
When the patient reclines on a couch with the analyst out of
view, the patient tends to remember more experiences, more resistance
and transference, and is 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).
Various memories of early life are generally distorted – Freud called
them "screen memories" – and in any case, very early experiences (before
age two) – cannot 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, supplemented by the work of John Bowlby and Mary Ainsworth, 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 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.
Interpersonal–relational psychoanalysts emphasize the notion that it is impossible to be neutral. Sullivan
introduced the term "participant-observer" to indicate the analyst
inevitably interacts with the analysand, and suggested the detailed
inquiry as an alternative to interpretation. The detailed inquiry
involves noting where the analysand is leaving out important elements of
an account and noting when the story is obfuscated, and asking careful
questions to open up the dialogue.
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 first decade of the 21st century
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.
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 counselor 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 psychodynamic 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.
As a result of the defense mechanisms
and the lack of access to the unfathomable elements of the unconscious,
psychoanalysis can be an expansive process that involves 2 to 5
sessions per week for several years. This type of therapy relies on the
belief that reducing the symptoms will not actually help with the root
causes or irrational drives. The analyst typically is a 'blank screen',
disclosing very little about themselves in order that the client can use
the space in the relationship to work on their unconscious without
interference from outside.
The psychoanalyst uses various methods to help the patient to
become more self-aware and to develop insights into their behavior and
into the meanings of symptoms. First and foremost, the psychoanalyst
attempts to develop a confidential atmosphere in which the patient can
feel safe reporting his feelings, thoughts and fantasies. Analysands (as
people in analysis are called) are asked to report whatever comes to
mind without fear of reprisal. Freud called this the "fundamental
rule". Analysands are asked to talk about their lives, including their
early life, current life and hopes and aspirations for the future. They
are encouraged to report their fantasies, "flash thoughts" and dreams.
In fact, Freud believed that dreams were, "the royal road to the
unconscious"; he devoted an entire volume to the interpretation of
dreams. Also, psychoanalysts encourage their patients to recline on a
couch. Typically, the psychoanalyst sits, out of sight, behind the
patient.
The psychoanalyst's task, in collaboration with the analysand, is
to help deepen the analysand's understanding of those factors, outside
of his awareness, that drive his behaviors. In the safe environment of
the psychoanalytic setting, the analysand becomes attached to the
analyst and pretty soon he begins to experience the same conflicts with
his analyst that he experiences with key figures in his life such as his
parents, his boss, his significant other, etc. It is the
psychoanalyst's role to point out these conflicts and to interpret them.
The transferring of these internal conflicts onto the analyst is called
"transference".
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.
Training and research
United States
Psychoanalytic
training in the United States involves a personal psychoanalysis for
the trainee, approximately 600 hours of class instruction, with a
standard curriculum, over a four or five-year period.
Typically, this psychoanalysis must be conducted by a Supervising
and Training Analyst. Most institutes (but not all) within the American
Psychoanalytic Association, require that Supervising and Training
Analysts become certified by the American Board of Psychoanalysts.
Certification entails a blind review in which the psychoanalysts work is
vetted by psychoanalysts outside of their local community. After
earning certification, these psychoanalysts undergo another hurdle in
which they are specially vetted by senior members of their own
institute. Supervising and Training analysts are held to the highest
clinical and ethical standards. Moreover, they are required to have
extensive experience conducting psychoanalyses.
Similarly, class instruction for psychoanalytic candidates is
rigorous. Typically classes meet several hours a week, or for a full day
or two every other weekend during the academic year; this varies with
the institute.
Candidates generally have an hour of supervision each week, with a
Supervising and Training Analyst, on each psychoanalytic case. 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
psychoanalytic work that week. In supervision, the patient's unconscious
conflicts are explored, also, transference-countertransference
constellations are examined. Also, clinical technique is taught.
Many psychoanalytic training centers in the United States have
been accredited by special committees of the APsaA or the IPA. Because
of theoretical differences, there are independent institutes, usually
founded by psychologists, who until 1987 were not permitted access to
psychoanalytic training institutes of the APsaA. Currently there are
between 75 and 100 independent institutes in the United States. As
well, other institutes are affiliated to other organizations such as the
American Academy of Psychoanalysis and Dynamic Psychiatry,
and the National Association for the Advancement of Psychoanalysis. At
most psychoanalytic institutes in the United States, qualifications for
entry include a terminal degree in a mental health field, such as Ph.D.,
Psy.D., M.S.W., or M.D. A few institutes restrict applicants to those
already holding an M.D. or Ph.D., and most institutes in Southern
California confer a Ph.D. or Psy.D.
in psychoanalysis upon graduation, which involves completion of the
necessary requirements for the state boards that confer that doctoral
degree. The first training institute in America to educate non-medical
psychoanalysts was The National Psychological Association for
Psychoanalysis (1978) in New York City. It was founded by the analyst
Theodor Reik. The Contemporary Freudian (originally the New York
Freudian Society) an offshoot of the National Psychological Association
has a branch in Washington, DC. It is a component society/institute or
the IPA.
Some psychoanalytic training has been set up as a post-doctoral
fellowship in university settings, such as at Duke University, Yale
University, New York University, Adelphi University and Columbia
University. Other psychoanalytic institutes may not be directly
associated with universities, but the faculty at those institutes
usually hold contemporaneous faculty positions with psychology Ph.D.
programs and/or with medical school psychiatry residency programs.
The IPA is the world's primary accrediting and regulatory body
for psychoanalysis. Their mission is to assure the continued vigor and
development of psychoanalysis for the benefit of psychoanalytic
patients. It works in partnership with its 70 constituent organizations
in 33 countries to support 11,500 members. In the US, there are 77
psychoanalytical organizations, institutes associations in the United
States, which are spread across the states of America. APSaA has 38
affiliated societies which have 10 or more active members who practice
in a given geographical area. The aims of APSaA and other
psychoanalytical organizations are: provide ongoing educational
opportunities for its members, stimulate the development and research of
psychoanalysis, provide training and organize conferences. There are
eight affiliated study groups in the United States. A study group is the
first level of integration of a psychoanalytical body within the IPA,
followed by a provisional society and finally a member society.
The Division of Psychoanalysis (39) of the American Psychological Association
(APA) was established in the early 1980s by several psychologists.
Until the establishment of the Division of Psychoanalysis, psychologists
who had trained in independent institutes had no national organization.
The Division of Psychoanalysis now has approximately 4,000 members and
approximately 30 local chapters in the United States. The Division of
Psychoanalysis holds two annual meetings or conferences and offers
continuing education in theory, research and clinical technique, as do
their affiliated local chapters. The European Psychoanalytical
Federation (EPF) is the organization which consolidates all European
psychoanalytic societies. This organization is affiliated with the IPA.
In 2002 there were approximately 3,900 individual members in 22
countries, speaking 18 different languages. There are also 25
psychoanalytic societies.
The American Association of Psychoanalysis in Clinical Social
Work (AAPCSW) was established by Crayton Rowe in 1980 as a division of
the Federation of Clinical Societies of Social Work and became an
independent entity in 1990. Until 2007 it was known as the National
Membership Committee on Psychoanalysis. The organization was founded
because although social workers represented the larger number of people
who were training to be psychoanalysts, they were underrepresented as
supervisors and teachers at the institutes they attended. AAPCSW now
has over 1000 members and has over 20 chapters. It holds a bi-annual
national conference and numerous annual local conferences.
Experiences of psychoanalysts and psychoanalytic psychotherapists
and research into infant and child development have led to new
insights. Theories have been further developed and the results of empirical research are now more integrated in the psychoanalytic theory.
United Kingdom
The London Psychoanalytical Society was founded by Ernest Jones on 30 October 1913. With the expansion of psychoanalysis in the United Kingdom the Society was renamed the British Psychoanalytical Society
in 1919. Soon after, the Institute of Psychoanalysis was established to
administer the Society’s activities. These include: the training of
psychoanalysts, the development of the theory and practice of
psychoanalysis, the provision of treatment through The London Clinic of
Psychoanalysis, the publication of books in The New Library of
Psychoanalysis and Psychoanalytic Ideas. The Institute of Psychoanalysis
also publishes The International Journal of Psychoanalysis,
maintains a library, furthers research, and holds public lectures. The
society has a Code of Ethics and an Ethical Committee. The society, the
institute and the clinic are all located at Byron House.
The society is a component of the IPA, a body with members on all
five continents that safeguards professional and ethical practice. The
society is a member of the British Psychoanalytic Council (BPC); the BPC
publishes a register of British psychoanalysts and psychoanalytical
psychotherapists. All members of the British Psychoanalytical Society
are required to undertake continuing professional development.
Members of the Society have included Michael Balint, Wilfred Bion, John Bowlby, Anna Freud, Melanie Klein, Joseph J. Sandler, and Donald Winnicott.
The Institute of Psychoanalysis is the foremost publisher of psychoanalytic literature. The 24-volume Standard Edition of the Complete Psychological Works of Sigmund Freud
was conceived, translated, and produced under the direction of the
British Psychoanalytical Society. The Society, in conjunction with Random House,
will soon publish a new, revised and expanded Standard Edition. With
the New Library of Psychoanalysis the Institute continues to publish the
books of leading theorists and practitioners. The International Journal of Psychoanalysis
is published by the Institute of Psychoanalysis. Now in its 84th year,
it has one of the largest circulations of any psychoanalytic journal.
Research
Over a hundred years of case reports and studies in the journal Modern Psychoanalysis, the Psychoanalytic Quarterly, the International Journal of Psychoanalysis and the Journal of the American Psychoanalytic Association have analyzed the efficacy of analysis in cases of neurosis and character or personality
problems. Psychoanalysis modified by object relations techniques has
been shown to be effective in many cases of ingrained problems of
intimacy and relationship (cf. the many books of Otto Kernberg).
Psychoanalytic treatment, in other situations, may run from about a year
to many years, depending on the severity and complexity of the
pathology.
Psychoanalytic theory has, from its inception, been the subject
of criticism and controversy. Freud remarked on this early in his
career, when other physicians in Vienna ostracized him for his findings
that hysterical conversion symptoms were not limited to women.
Challenges to analytic theory began with Otto Rank and Alfred Adler (turn of the 20th century), continued with behaviorists (e.g. Wolpe) into the 1940s and '50s, and have persisted (e.g. Miller).
Criticisms come from those who object to the notion that there are
mechanisms, thoughts or feelings in the mind that could be unconscious.
Criticisms also have been leveled against the idea of "infantile
sexuality" (the recognition that children between ages two and six
imagine things about procreation). Criticisms of theory have led to
variations in analytic theories, such as the work of Ronald Fairbairn, Michael Balint, and John Bowlby. In the past 30 years or so, the criticisms have centered on the issue of empirical verification.
Psychoanalysis has been used as a research tool into childhood development (cf. the journal The Psychoanalytic Study of the Child), and has developed into a flexible, effective treatment for certain mental disturbances. In the 1960s, Freud's early (1905) thoughts on the childhood development of female sexuality
were challenged; this challenge led to major research in the 1970s and
80s, and then to a reformulation of female sexual development that
corrected some of Freud's concepts. Also see the various works of Eleanor Galenson, Nancy Chodorow, Karen Horney, Françoise Dolto, Melanie Klein, Selma Fraiberg,
and others. Most recently, psychoanalytic researchers who have
integrated attachment theory into their work, including Alicia
Lieberman, Susan Coates, and Daniel Schechter
have explored the role of parental traumatization in the development of
young children's mental representations of self and others.
There are different forms of psychoanalysis and psychotherapies in which psychoanalytic thinking is practiced. Besides classical psychoanalysis there is for example psychoanalytic psychotherapy,
a therapeutic approach which widens "the accessibility of
psychoanalytic theory and clinical practices that had evolved over 100
plus years to a larger number of individuals." Other examples of well known therapies which also use insights of psychoanalysis are mentalization-based treatment (MBT), and transference focused psychotherapy (TFP). There is also a continuing influence of psychoanalytic thinking in mental health care.
Evaluation of effectiveness
Background
The psychoanalytic profession has been resistant to researching efficacy. Effectiveness measures based on the interpretation of the therapist alone cannot be proven.
Research results
Research results have tended to support views of long-term efficacy.
A 2015 study found evidence of better long-term outcomes for depression after psychoanalysis.
Meta-analyses in 2012 and 2013 found support or evidence for the efficacy of psychoanalytic therapy, thus further research is needed. Other meta-analyses published in the recent years showed psychoanalysis and psychodynamic therapy to be effective, with outcomes comparable or greater than other kinds of psychotherapy or antidepressant drugs, but these arguments have also been subjected to various criticisms.
In particular, the inclusion of pre/post studies rather than randomized
controlled trials, and the absence of adequate comparisons with control
treatments is a serious limitation in interpreting the results .
In 2011, the American Psychological Association made 103
comparisons between psychodynamic treatment and a non-dynamic competitor
and found that 6 were superior, 5 were inferior, 28 had no difference
and 63 were adequate. The study found that this could be used as a basis
"to make psychodynamic psychotherapy an 'empirically validated'
treatment."
Meta-analyses of Short Term Psychodynamic Psychotherapy (STPP) have found effect sizes ranging from .34–.71 compared to no treatment and was found to be slightly better than other therapies in follow up. Other reviews have found an effect size of .78–.91 for somatic disorders compared to no treatment and .69 for treating depression. A 2012 meta-analysis by the Harvard Review of Psychiatry
of Intensive Short-Term Dynamic Psychotherapy (ISTDP) found effect
sizes ranging from .84 for interpersonal problems to 1.51 for
depression. Overall ISTDP had an effect size of 1.18 compared to no
treatment.
A meta-analysis of Long Term Psychodynamic Psychotherapy in 2012
found an overall effect size of .33, which is modest. This study
concluded the recovery rate following LTPP was equal to control
treatments, including treatment as usual, and found the evidence for the
effectiveness of LTPP to be limited and at best conflicting. Others have found effect sizes of .44–.68.
According to a 2004 French review conducted by INSERM, psychoanalysis was presumed or proven effective at treating panic disorder, post-traumatic stress and personality disorders.
The world's largest randomized controlled trial on therapy with anorexia nervosa outpatients, the ANTOP-Study, published 2013 in The Lancet, found evidence that modified psychodynamic therapy is effective in increasing body mass index
after a 10-month treatment and that the effect is persistent until at
least a year after concluding the treatment. Relative to other
treatments assigned, it was found to be as effective in increasing body
mass index as cognitive behavioral therapy and as a standard treatment
protocol (which consisted of referral to a list of psychotherapists with
experience in treating eating-disorders in addition to close monitoring
and treatment by a family doctor). Furthermore, considering the outcome
to be the recovery rate one year after the treatment, measured by the
proportion of patients who no longer met the diagnostic criteria for
anorexia nervosa, modified psychodynamic therapy was found to be more
effective than the standard treatment protocol and as effective as
cognitive behavioral therapy.
A 2001 systematic review of the medical literature by the Cochrane Collaboration
concluded that no data exist demonstrating that psychodynamic
psychotherapy is effective in treating schizophrenia and severe mental
illness, and cautioned that medication should always be used alongside
any type of talk therapy in schizophrenia cases. A French review from 2004 found the same. The Schizophrenia Patient Outcomes Research Team advises against the use of psychodynamic therapy in cases of schizophrenia, arguing that more trials are necessary to verify its effectiveness.
Criticism
As a field of science
The strongest reason for considering Freud a pseudo-scientist is that he claimed to have tested – and thus to have provided the most cogent grounds for accepting – theories which are either untestable or even if testable had not been tested. It is spurious claims to have tested an untestable or untested theory which are the most pertinent grounds for deeming Freud and his followers pseudoscientists...—Frank Cioffi
Both Freud and psychoanalysis have been criticized in very extreme terms.
Exchanges between critics and defenders of psychoanalysis have often
been so heated that they have come to be characterized as the Freud Wars.
Early critics of psychoanalysis believed that its theories were based too little on quantitative and experimental research, and too much on the clinical case study method. Some have accused Freud of fabrication, most famously in the case of Anna O. The philosopher Frank Cioffi
cites false claims of a sound scientific verification of the theory and
its elements as the strongest basis for classifying the work of Freud
and his school as pseudoscience.
Others have speculated that patients suffered from now easily
identifiable conditions unrelated to psychoanalysis; for instance, Anna
O. is thought to have suffered from an organic impairment such as tuberculous meningitis or temporal lobe epilepsy and not hysteria.
Karl Popper argued that psychoanalysis is a pseudoscience because its claims are not testable and cannot be refuted; that is, they are not falsifiable. Imre Lakatos
later wrote that, "Freudians have been nonplussed by Popper's basic
challenge concerning scientific honesty. Indeed, they have refused to
specify experimental conditions under which they would give up their
basic assumptions." The philosopher Roger Scruton, writing in Sexual Desire
(1986), rejected Popper's arguments, pointing to the theory of
repression as an example of a Freudian theory that does have testable
consequences. Scruton nevertheless concluded that psychoanalysis is not
genuinely scientific, on the grounds that it involves an unacceptable
dependence on metaphor.
Cognitive scientists, in particular, have also weighed in. Martin Seligman, a prominent academic in positive psychology
wrote, "Thirty years ago, the cognitive revolution in psychology
overthrew both Freud and the behaviorists, at least in academia. ...
[T]hinking ... is not just a [result] of emotion or behavior. ...
[E]motion is always generated by cognition, not the other way around." Linguist Noam Chomsky has criticized psychoanalysis for lacking a scientific basis. Steven Pinker considers Freudian theory unscientific for understanding the mind. Evolutionary biologist Steven Jay Gould considered psychoanalysis influenced by pseudoscientific theories such as recapitulation theory. Psychologists Hans Eysenck and John F. Kihlstrom have also criticized the field as pseudoscience.
Adolf Grünbaum argues in Validation in the Clinical Theory of Psychoanalysis
(1993) that psychoanalytic based theories are falsifiable, but that the
causal claims of psychoanalysis are unsupported by the available
clinical evidence.
Richard Feynman wrote off psychoanalysts as mere "witch doctors":
If you look at all of the complicated ideas that they have developed in an infinitesimal amount of time, if you compare to any other of the sciences how long it takes to get one idea after the other, if you consider all the structures and inventions and complicated things, the ids and the egos, the tensions and the forces, and the pushes and the pulls, I tell you they can't all be there. It's too much for one brain or a few brains to have cooked up in such a short time.
The psychiatrist E. Fuller Torrey, in Witchdoctors and Psychiatrists
(1986), agreed that psychoanalytic theories have no more scientific
basis than the theories of traditional native healers, "witchdoctors" or
modern "cult" alternatives such as est. Psychologist Alice Miller charged psychoanalysis with being similar to the poisonous pedagogies, which she described in her book For Your Own Good. She scrutinized and rejected the validity of Freud's drive theory, including the Oedipus complex, which, according to her and Jeffrey Masson, blames the child for the abusive sexual behavior of adults.
Psychologist Joel Kupfersmid investigated the validity of the Oedipus
complex, examining its nature and origins. He concluded that there is
little evidence to support the existence of the Oedipus complex.
Michel Foucault and Gilles Deleuze claimed that the institution of psychoanalysis has become a center of power and that its confessional techniques resemble the Christian tradition. Jacques Lacan
criticized the emphasis of some American and British psychoanalytical
traditions on what he has viewed as the suggestion of imaginary "causes"
for symptoms, and recommended the return to Freud. Together with Deleuze, Félix Guattari criticised the Oedipal structure. Luce Irigaray criticised psychoanalysis, employing Jacques Derrida's concept of phallogocentrism to describe the exclusion of the woman from Freudian and Lacanian psychoanalytical theories. Deleuze and Guattari, in their 1972 work Anti-Œdipus, take the cases of Gérard Mendel, Bela Grunberger and Janine Chasseguet-Smirgel, prominent members of the most respected associations (IPa), to suggest that, traditionally, psychoanalysis enthusiastically embraces a police state.
The theoretical foundations of psychoanalysis lie in the same philosophical currents that lead to interpretive phenomenology rather than in those that lead to scientific positivism, making the theory largely incompatible with positivist approaches to the study of the mind.
Although numerous studies have shown that the efficacy of therapy is primarily related to the quality of the therapist, rather than the school or technique or training, a French 2004 report from INSERM concluded that psychoanalytic therapy is less effective than other psychotherapies (including cognitive behavioral therapy) for certain diseases. This report used a meta-analysis of numerous other studies to find whether the treatment was "proven" or "presumed" to be effective on different diseases.
Freudian theory
Many aspects of Freudian theory are indeed out of date, and they should be: Freud died in 1939, and he has been slow to undertake further revisions. His critics, however, are equally behind the times, attacking Freudian views of the 1920s as if they continue to have some currency in their original form. Psychodynamic theory and therapy have evolved considerably since 1939 when Freud's bearded countenance was last sighted in earnest. Contemporary psychoanalysts and psychodynamic therapists no longer write much about ids and egos, nor do they conceive of treatment for psychological disorders as an archaeological expedition in search of lost memories.—Drew Westen
An increasing amount of empirical research from academic psychologists and psychiatrists has begun to address this criticism.
A survey of scientific research suggested that while personality traits
corresponding to Freud's oral, anal, Oedipal, and genital phases can be
observed, they do not necessarily manifest as stages in the development
of children. These studies also have not confirmed that such traits in
adults result from childhood experiences (Fisher & Greenberg, 1977,
399). However, these stages should not be viewed as crucial to modern
psychoanalysis. What is crucial to modern psychoanalytic theory and
practice is the power of the unconscious and the transference
phenomenon.
The idea of "unconscious" is contested because human behavior can
be observed while human mental activity has to be inferred. However,
the unconscious is now a popular topic of study in the fields of
experimental and social psychology (e.g., implicit attitude measures, fMRI, and PET scans,
and other indirect tests). The idea of unconscious, and the
transference phenomenon, have been widely researched and, it is claimed,
validated in the fields of cognitive psychology
and social psychology (Westen & Gabbard 2002), though a Freudian
interpretation of unconscious mental activity is not held by the
majority of cognitive psychologists. Recent developments in neuroscience
have resulted in one side arguing that it has provided a biological
basis for unconscious emotional processing in line with psychoanalytic
theory i.e., neuropsychoanalysis (Westen & Gabbard 2002), while the other side argues that such findings make psychoanalytic theory obsolete and irrelevant.
Shlomo Kalo explains that the scientific materialism that flourished in the 19th century severely harmed religion and rejected whatever called spiritual. The institution of the confession
priest in particular was badly damaged. The empty void that this
institution left behind was swiftly occupied by the newborn
psychoanalysis. In his writings Kalo claims that psychoanalysis basic
approach is erroneous. It represents the mainline wrong assumptions that
happiness is unreachable and that the natural desire of a human being
is to exploit his fellow men for his own pleasure and benefit.
Jacques Derrida incorporated aspects of psychoanalytic theory into his theory of deconstruction in order to question what he called the 'metaphysics of presence'.
Derrida also turns some of these ideas against Freud, to reveal
tensions and contradictions in his work. For example, although Freud
defines religion and metaphysics as displacements of the identification
with the father in the resolution of the Oedipal complex, Derrida
insists in The Postcard: From Socrates to Freud and Beyond that
the prominence of the father in Freud's own analysis is itself indebted
to the prominence given to the father in Western metaphysics and
theology since Plato.
Outlook
Psychoanalysis
continues to be practiced by psychiatrists, social workers, and other
mental health professionals; however, its practice has declined.
In 2015 Bradley Peterson, a psychoanalyst, child psychiatrist and the director of the Institute for the Developing Mind at Children's Hospital Los Angeles, said "I think most people would agree that psychoanalysis as a form of treatment is on its last legs", says . However psychoanalytic approaches continue to be listed by the UK NHS as possibly helpful for depression.
