Psychoanalysis is a set of theories and therapeutic techniques that deal in part with the unconscious mind, and which together form a method of treatment for mental disorders. The discipline was established in the early 1890s by Sigmund Freud, whose work stemmed partly from the clinical work of Josef Breuer
and others. Freud developed and refined the theory and practice of
psychoanalysis until his death in 1939. In an encyclopedia article, he
identified the cornerstones of psychoanalysis as "the assumption that
there are unconscious mental processes, the recognition of the theory of
repression and resistance, the appreciation of the importance of
sexuality and of the Oedipus complex." Freud's students Alfred Adler and Carl Gustav Jung developed offshoots of psychoanalysis which they called individual psychology (Adler) and Analytical Psychology
(Jung), although Freud himself wrote a number of criticisms of them and
emphatically denied that they were forms of psychoanalysis. Psychoanalysis was later developed in different directions by neo-Freudian thinkers, such as Erich Fromm, Karen Horney, and Harry Stack Sullivan.
Freud distinguished between a conscious and unconscious mind, arguing that the unconscious mind largely determines behaviour and cognition owing to unconscious drives. Freud observed that attempts to bring such drives into awareness triggers resistance in the form of defense mechanisms, particularly repression,
and that conflicts between conscious and unconscious material can
result in mental disturbances. He also postulated that unconscious
material can be found in dreams and unintentional acts, including mannerisms and Freudian slips.
Psychoanalytic therapy developed as a means to improve mental health by
bringing unconscious material into consciousness. Psychoanalysts place a
large emphasis on early childhood in an individual's development. During therapy, a psychoanalyst aims to induce transference, whereby patients relive their infantile conflicts by projecting onto the analyst feelings of love, dependence and anger.
During psychoanalytic sessions a patient traditionally lies on a
couch, and an analyst sits just behind and out of sight. The patient
expresses their 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 defence mechanisms to help the patient understand
themselves better.
Psychoanalysis is a controversial discipline, and its
effectiveness as a treatment has been contested, although it retains
influence within psychiatry. Psychoanalytic concepts are also widely used outside the therapeutic arena, in areas such as psychoanalytic literary criticism and film criticism, analysis of fairy tales, philosophical perspectives such as Freudo-Marxism, and other cultural phenomena.
History
1890s
The idea of psychoanalysis (German: Psychoanalyse) first began 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 he 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 photographic representation of clinical symptoms.
Freud's first theory to explain hysterical symptoms was presented in Studies on Hysteria (1895; Studien über Hysterie), 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 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 term 'psychoanalysis' (psychoanalyse) was first introduced by Freud in his essay titled "Heredity and etiology of neuroses" ("L'hérédité et l'étiologie des névroses"), written and published in French in 1896.
In 1896, Freud also published his seduction theory,
claiming to have uncovered repressed memories of incidents of sexual
abuse for all his current patients, from which he proposed that the
preconditions for hysterical symptoms are sexual excitations in infancy.
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. 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.
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.
In the latter part of the 20th century, several Freud scholars
challenged Freud's perception of the patients who informed him of
childhood sexual abuse, arguing that he had imposed his preconceived
notions on his patients.
By 1899, Freud had theorised that dreams had symbolic
significance, and generally were specific to the dreamer. Freud
formulated his second psychological theory—which hypotheses 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, which Freud thought of as his most significant work. Freud outlined a new topographic theory,
which theorised that unacceptable sexual wishes were repressed into the
"System Unconscious". These wishes were made 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, where it has been largely supplanted by structural theory. In addition, The Interpretation of Dreams contained Freud's first conceptualisation of the Oedipal complex,
which asserted that young boys are sexually attracted to their mothers
and envious of their fathers for being able to have sex with their
mothers.
Psychologist Frank Sulloway in his book Freud, Biologist of the Mind: Beyond the Psychoanalytic Legend argues that Freud's biological theories like libido were rooted in the biological hypothesis that accompanied the work of Charles Darwin, citing theories of Krafft-Ebing, Molland, Havelock Ellis, Haeckel, Wilhelm Fliess as influencing Freud.
1900–1940s
In 1905, Freud published Three Essays on the Theory of Sexuality in which he laid out his discovery of the psychosexual phases,
which categorised early childhood development into five stages
depending on what sexual afinity a child possessed at the stage:
- Oral (ages 0–2);
- Anal (2–4);
- Phallic-oedipal or First 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 result in
anxiety or physical symptoms. 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 titular subject of narcissism.
Freud characterized the difference between energy directed at the self
versus energy directed at others using a system known as cathexis. By 1917, in "Mourning and Melancholia", he suggested that certain depressions were caused by turning guilt-ridden anger on the self. In 1919, through "A Child is Being Beaten", he began to address the problems of self-destructive behavior and 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 in Group Psychology and the Analysis of the Ego. In that same year, 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 of three new
concepts id, ego, and superego.
Three years later, in 1923, 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 caused anxiety, and how that anxiety could lead to an inhibition of mental functions, such as intellect and speech. In 1924, Otto Rank published The Trauma of Birth, which analysed culture and philosophy in relation to separation anxiety which occurred before the development of an Oedipal 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 Freud's 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, the group built upon understandings of the synthetic function of the ego as a mediator in psychic functioning, distinguishing such from autonomous
ego functions (e.g. memory and intellect). 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 growing interest in child psychoanalysis. 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. 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.
Psychoanalysis as a movement
Freud founded the Psychological Wednesday Society in 1902, which Edward Shorter argues was the beginning of psychoanalysis as a movement. This society became the Vienna Psychoanalytic Society in 1908 in the same year as the first international congress of psychoanalysis held in Salzburg, Austria. Alfred Adler was one of the most active members in this society in its early years.
The second congress of psychoanalysis took place in Nuremberg, Germany in 1910. At this congress, Ferenczi called for the creation of an International Psychoanalytic Association with Jung as president for life. A third congress was held in Weimar in 1911. The London Psychoanalytical Society was founded in 1913 by Ernest Jones.
Developments of alternative forms of psychotherapy
Cognitive behavioural therapy (CBT)
In the 1950s, psychoanalysis was the main modality of psychotherapy. Behavioural models of psychotherapy started to assume a more central role in psychotherapy in the 1960s. Aaron T. Beck,
a psychiatrist trained in a psychoanalytic tradition, set out to test
the psychoanalytic models of depression empirically and found that
conscious ruminations of loss and personal failing were correlated with
depression. He suggested that distorted and biased beliefs were a causal
factor of depression, publishing an influential paper in 1967 after a
decade of research using the construct of schemas to explain the depression. Beck developed this empirically supported hypothesis for the cause of depression into a talking therapy called cognitive behavioral therapy (CBT) in the early 1970s.
Attachment theory
Attachment theory was developed theoretically by John Bowlby and formalized empirically by Mary Ainsworth. Bowlby was trained psychoanalytically but was concerned about some properties of psychoanalysis;
he was troubled by the dogmatism of psychoanalysis at the time, its
arcane terminology, the lack of attention to environment in child
behaviour, and the concepts derived from talking therapy to child
behaviour. In response, he developed an alternative conceptualization of child behaviour based on principles on ethology. Bowlby's theory of attachment rejects Freud's model of psychosexual development based on the Oedipal model.
For his work, Bowlby was shunned from psychoanalytical circles who did
not accept his theories. Nonetheless, his conceptualization was adopted
widely by mother-infant research in the 1970s.
Theories
The
predominant psychoanalytic theories can be organised into several
theoretical schools. Although these perspectives 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.
There are some persistent conflicts among psychoanalysts
regarding specific causes of certain syndromes, and some disputes
regarding the ideal treatment techniques. In the 21st century,
psychoanalytic ideas have found influence in fields such as childcare, education, literary criticism, cultural studies, mental health, and particularly psychotherapy.
Though most mainstream psychoanalysts subscribe to modern strains of
psychaoanalytical thought, there are groups who follow the precepts of a
single psychoanalyst and their school of thought. 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.
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), while major steps forward would be made through 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 mental processes.
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:
- Topographic
- Dynamic (the theory of conflict)
- Economic (the theory of energy flow)
- Structural
- Genetic (i.e. propositions concerning origin and development of psychological functions)
- Adaptational (i.e. 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. 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 who follow the work of Charles Brenner, especially The Mind in Conflict (1982), include Sandor Abend, Jacob Arlow, and Jerome Blackman.
Object relations theory
Object relations theory attempts to explain human relationships through a study of how mental 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.
Klein discusses the concept of introjection, creating a mental representation of external objects; and projection, applying this mental representation to reality. Wilfred Bion introduced the concept of containment
of projections in the mother-child relationship where a mother
understands an infants projections, modifies them and returns them to
the child.
Concepts regarding internal representation (aka 'introspect',
'self and object representation', 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.
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. Mahler,
Fine, and Bergman (1975) describe 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,
internalizations, stability of affect management, and ability to develop
healthy autonomy.
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,
Identity, Closeness, and Stability) in relationships, 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.
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. 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.
Adaptive paradigm
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. Relational psychoanalysts 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.
Psychopathology (mental disturbances)
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 (i.e. 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.
Oedipal conflicts
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, in which the protagonist unwittingly kills his father and marries his mother. 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. 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
(aka 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 are also important. The analyst is interested in how the patient reacts to and avoids such fantasies. Various memories of early life are generally distorted—what Freud called screen memories—and in any case, very early experiences (before age two)—cannot be remembered.
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 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 (see also the studies and opinion papers of Owen
Renik). "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. 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. 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.
Using toys and games, children are able to symbolically demonstrate
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. 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.
Psychodynamic therapy
Psychodynamic
therapies refer therapies that draw from psychoanalytic approaches but
are designed to be shorter in duration or less intensive.
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,
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. Freud had his patients lay on a couch in a dimly lit room and
would sit out of sight, usually directly behind them, as to not
influence the patients thoughts by his gestures or expressions.
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
Psychoanalysis
continues to be practiced by psychiatrists, social workers, and other
mental health professionals; however, its practice has declined. It has been largely replaced by the similar but broader psychodynamic psychotherapy in the mid-20th century. Psychoanalytic approaches continue to be listed by the UK National Health Service as possibly helpful for depression.
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 psychoanalyst's 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 and associations, which are
spread across the states. 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. After World War I with the expansion of psychoanalysis in the United Kingdom, the Society was reconstituted and named 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 in West London.
The Society is a constituent society of the International Psychoanalytical Association (IPA) a body with members on all five continents which 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
Psychoanalytic Council are required to undertake continuing professional development, CPD. Members of the Society teach and hold posts on other approved psychoanalytic courses, e.g.: British Psychotherapy Foundation and in academic departments, e.g.University College London.
Members of the Society have included: Michael Balint, Wilfred Bion, John Bowlby, Ronald Fairbairn, Anna Freud, Harry Guntrip, Melanie Klein, Donald Meltzer, Joseph J. Sandler, Hanna Segal, J. D. Sutherland 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.
Psychoanalytic psychotherapy
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.
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.
Effectiveness
The psychoanalytic profession has been resistant to researching efficacy. Evaluations of effectiveness based on the interpretation of the therapist alone cannot be proven.
Research results
Numerous
studies have shown that the efficacy of therapy is primarily related to
the quality of the therapist, rather than to the school or technique or
training.
Meta-analyses in 2012 and 2013 found support or evidence for the efficacy of psychoanalytic therapy, but further research is needed. Other meta-analyses published in recent years showed psychoanalysis and psychodynamic therapy to be effective, with outcomes comparable to or greater than other kinds of psychotherapy or antidepressant drugs, but these meta-analyses have 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. A French 2004 report from INSERM concluded that psychoanalytic therapy is less effective than other psychotherapies (including cognitive behavioral therapy) for certain diseases.
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 showed 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 (Cohen's d) ranging from 0.34 to 0.71 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 0.78 to 0.91 for somatic disorders compared to no treatment and 0.69 for treating depression. A 2012 Harvard Review of Psychiatry
meta-analysis of Intensive Short-Term Dynamic Psychotherapy (ISTDP)
found effect sizes ranging from 0.84 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 0.33, 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 0.44–0.68.
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, but did not find evidence of its effectiveness in treating schizophrenia, obsessive compulsive disorder, specific phobia, bulimia and anorexia.
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
Both Freud and psychoanalysis have been criticized in 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. Linguist Noam Chomsky has criticized psychoanalysis for lacking a scientific basis. Evolutionary biologist Stephen Jay Gould considered psychoanalysis influenced by pseudoscientific theories such as recapitulation theory. Psychologists Hans Eysenck, John F. Kihlstrom, and others have also criticized the field as pseudoscience.
Debate over status as scientific
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.
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. 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.
Karl Popper argued that psychoanalysis is a pseudoscience because its claims are not testable and cannot be refuted; that is, they are not falsifiable:
....those
"clinical observations" which analysts naively believe confirm their
theory cannot do this any more than the daily confirmations which
astrologers find in their practice. And as for Freud's epic of the Ego,
the Super-ego, and the Id, no substantially stronger claim to scientific
status can be made for it than for Homer's collected stories from the
Olympus.
In addition, Imre Lakatos
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." In Sexual Desire (1986), philosopher Roger Scruton
rejects 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. The philosopher and physicist Mario Bunge argued that psychoanalysis is a pseudoscience because it violates the ontology and methodology inherent to science. According to Bunge, most psychoanalytic theories are either untestable or unsupported by evidence.
Cognitive scientists, in particular, have also weighed in. Martin Seligman, a prominent academic in positive psychology, wrote that:
Thirty
years ago, the cognitive revolution in psychology overthrew both Freud
and the behaviorists, at least in academia.… The imperialistic Freudian
view claims that emotion always drives thought, while the imperialistic
cognitive view claims that thought always drives emotion. The evidence,
however, is that each drives the other at times.
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.
Historian Henri Ellenberger, who researched the history of Freud, Jung, Adler, and Janet, while writing his book The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry, argued that psychoanalysis was not scientific on the grounds of both its methodology and social structure:
Psychoanalysis, is it a
science? It does not meet the criteria (unified science, defined
domain and methodology). It corresponds to the traits of a philosophical
sect (closed organisation, highly personal initiation, a doctrine which
is changeable but defined by its official adoption, cult and legend of
the founder).
— Henri Ellenberger
Freud
Some have accused Freud of fabrication, most famously in the case of Anna O.
Others have speculated that patients had conditions that are now easily
identifiable and unrelated to psychoanalysis; for instance, Anna O. is
thought to have had an organic impairment such as tuberculous meningitis or temporal lobe epilepsy, rather than Freud's diagnosis of hysteria.
Henri Ellenberger and Frank Sulloway argue that Freud and his followers created an inaccurate legend of Freud to popularize psychoanalysis. Borch-Jacobson and Shamdasani argue that this legend has been adapted to different times and situations. Isabelle Stengers states that psychoanalytic circles have tried to stop historians from accessing documents about the life of Freud.
Witch doctors
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.
Likewise, 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.
Critical perspectives
Contemporary French philosophers Michel Foucault and Gilles Deleuze asserted that the institution of psychoanalysis has become a center of power, and that its confessional techniques resemble those included and utilized within the Christian religion. French psychoanalyst 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, the French psychoanalyst and psychiatrist Félix Guattari criticized the Oedipal and schizophrenic power structure of psychoanalysis and its connivance with capitalism in Anti-Oedipus (1972) and A Thousand Plateaus (1980), the two volumes of their theoretical work Capitalism and Schizophrenia. Belgian psycholinguist and psychoanalyst Luce Irigaray also criticized psychoanalysis, employing Jacques Derrida's concept of phallogocentrism to describe the exclusion of the woman both from Freudian and Lacanian psychoanalytical theories. Deleuze and Guattari in Anti-Oedipus take the cases of Gérard Mendel, Bela Grunberger, and Janine Chasseguet-Smirgel, prominent members of the most respected psychoanalytical associations (including the IPA), to suggest that, traditionally, psychoanalysis had always enthusiastically enjoyed and embraced a police state throughout its history.
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, 1998
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.
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,
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, 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 (1987)
insists 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.
.svg)
