Psychoanalysis and Psychodynamic Therapy

It has been over a century since Sigmund Freud first introduced psychoanalysis to the world and since “Anna O,” one of the earliest and most famous psychoanalytic patients, described the treatment she was receiving as “the talking cure.” Since those pioneering days of psychoanalysis, the influence of this theory can be seen in the myriad theories that have come into being either as extensions of psychoanalytic ideas or as reactions to them. Psychoanalysis is a form of treatment in which the client typically lies on the psychoanalyst’s couch and “free associates,” while coming multiple times per week over the course of several years. Psychodynamic psychotherapy utilizes the constructs that inform psychoanalysis proper, but clients typically sit facing their therapists and are seen for one or two appointments per week. Treatments are often of shorter duration and some interventions may be of only a few weeks. More generally, however, psychoanalytic concepts are used in a variety of treatment contexts, including group psychotherapy, assessment, and crisis intervention. Thus, psychoanalysis has been profoundly influential in mental health interventions far beyond the classical format of the patient on the couch.

Psychoanalytic theory is simultaneously a developmental theory, a personality theory, and a theory of intervention. Freud’s original instinctual theories emphasized the role of sexuality and aggression. Since that beginning, psychoanalysis has evolved in significant new directions. Significant developments include object relations theory (which emphasizes the way in which people’s history of relationships form part of their psychology and shape them in profound ways), ego psychology (which emphasizes the complex relationship between the evolving ego and reality), separation-individuation theory (which describes the trajectory from psychological symbiosis to a sense of autonomy), self psychology (which theorizes about narcissism as a normal developmental line and about the emotional forces that create and shape people’s sense of self), and relational and interpersonal models (which emphasize the interpersonal context of the therapeutic situation and its role in resolving conflicts).

Each of these psychoanalytic theories evolved from Freud’s original framework and each emphasizes different aspects of psychological development or different ways of intervening therapeutically. Today psychoanalysis or psychoanalytic treatments refer to this collection of concepts and theoretical positions that have evolved over the past century. Within psychoanalytic theory, there are schools that favor one of these views over others, and practitioners whose work may be more informed by one of these approaches over the others. These psychoanalytically informed therapies represent a complex set of assumptions and processes. They tend to be less directive or concretely problem solving in spirit than many other therapeutic approaches. Instead, they tend to emphasize the importance of insight and self-understanding as key curative elements in psychotherapy. Nevertheless, the different psychoanalytic schools are all derived from the core tenets of psychoanalytic theory and most psychoanalytic practitioners are conversant in all of these languages even if they emphasize one approach over the others in their own work.

Core Assumptions of Psychoanalysis

Notwithstanding this diversity of theoretical positions, psychoanalytic therapies tend to share certain core assumptions, such as the importance of the dynamic unconscious, the role of psychological defenses in mental functioning, and the importance of childhood experiences in shaping personality, including the conflicts that are the basis for psychopathology. The most central and fundamental of these shared constructs is the concept of the dynamic unconscious. One of Freud’s earliest observations, the dynamic unconscious centers on the idea that there are thoughts, feelings, memories, and experiences about which people are unaware or not fully aware that form part of their psychology. Unlike some theories of unconscious perception and cognition, however, the key to the psychoanalytic use of this concept is its emphasis on psychodynamic processes. In other words, it is not only that there are memories, thoughts, and feelings that exist outside of conscious awareness, but also that these influence human motivation and behavior. Furthermore, individuals have a powerful need to keep these thoughts and feelings out of awareness because their emergence into consciousness is all too often associated with problematic feelings such as anxiety, guilt, and shame. Thus, unconscious conflicts form the basis of our motivational processes and they play a complex role in every person’s life. This is true not only of specific symptomatic or pathological behaviors and patterns, but also of creative and other adaptive activities such as the choice of intimate partners, careers, and hobbies. The centrality of these unconscious processes makes them a key component to therapeutic efforts to address the problems of human living.

A closely related set of assumptions centers on the role and function of psychological defenses such as repression, denial, projection, displacement, and identification in emotional functioning. Anna Freud posited in her classic 1936 book, The Ego and the Mechanisms of Defense, that defenses were involved in both normal and pathological functioning. This groundbreaking work clarified the ways in which all people use defenses adaptively as part of their engagement with the reality around them. However, when defenses become entrenched, rigid, and immutable, they lead to symptomatic and broader pathological outcomes. For example, a child may not recognize the accumulating evidence that there is no Santa Claus for a time. Use of the defense of denial allows him or her to maintain the fantasy that there are magical, all-knowing, and kind people who love and take care of us and bring special, desired gifts. In the normal course of development, reality eventually imposes itself and children give up such magical beliefs. However, a child who grows up in a home that is emotionally depriving and harsh might not be able to outgrow the use of denial as a mechanism for clinging to wished-for realities. Such a child might give up the belief in Santa Claus (because to not do so would invite ridicule from peers and others), but continue to use denial in the context of relationships. This inappropriate use of denial could make it difficult for the child to see problematic qualities in others, thereby making him or her vulnerable to destructive relationships throughout life.

A third and related perspective that is shared by psychodynamic approaches is a strong commitment to a developmental framework. Psychodynamic approaches assume that experiences across the span of development, but especially in early childhood, play a vital role in shaping personality. For this reason, psychodynamic therapists pay close attention to their clients’ developmental histories. They seek to understand potentially important experiences, such as the attainment of developmental milestones, and events such as the birth of siblings, serious childhood illnesses, divorces, important family moves, the loss of important childhood attachments, and the psychological qualities and idiosyncrasies of the clients’ primary childhood caretakers. It is assumed that such experiences must be explored and their imprint on the adult personality must be understood if the therapist is to help clients with their concerns. Such variables may work together in complex ways. For example, the age at which particular events take place will play a role in the child’s capacity to understand and therefore on how its implications are absorbed. The same event (e.g., the death of a parent, the divorce of one’s parents, or being the victim of sexual molestation) may have a different psychological impact depending on when it transpired and whether the child’s primary caregivers help the child manage the painful overwhelming experience or compound its deleterious effects.

This developmental perspective incorporates a variety of thematic interpretations as to the relevant or important issues that govern a child’s development. The earliest and best known of these is Freud’s formulation of the first 6 years of development as progressing from oral, to anal, to oedipal phases, at which point, Freud theorized, the key components of personality development were in place. Freud argued that specific issues and challenges govern each of these phases. The oral phase, roughly the first 18 months of life, revolves around issues of nurturance, the stability of caregivers, and dependency. The anal phase, during the next 18 months, is ostensibly about the attainment of toilet training but, more to the point, is about the struggle for autonomy and independence. The oedipal phase, between 3 and 6 years of life, is about the consolidation of gender identity and identifications with parents. Complications in one of these phases lead, through fixation, to the issues central to that phase becoming implicated in personality structure and, for some, symptomatology.

The other schools that have been noted (ego psychology, object relations, separation-individuation theory, self psychology, and the relational and interpersonal schools) each tend to examine other developmental themes in greater depth. For example, ego psychology is especially interested in people’s ability to “test” reality adequately and regulate their emotions. Object relations theory examines how a person’s history of interpersonal relations structures his or her sense of self and others. Separation-individuation theory focuses on the struggle between a person’s wish to be dependent and his or her wish to be independent and autonomous. Self psychology looks at the evolution of a coherent sense of self and the ways in which people need and use others to organize themselves. Finally, the relational and interpersonal schools are especially attuned to how people re-create past relational patterns in current relationships, including therapeutic relationships.

Together, these models inform psychodynamic therapists about ways of understanding the issues, conflicts, and concerns that their clients bring into treatment. In effect, they provide a set of thematic guidelines that allow clinicians to understand these concerns as they arise in the clinical setting, and they help the clinician decide whether and how to communicate these understandings to the client. Because of this relation between theory and clinical inference, a strong association exists between psychoanalytic conceptualizations and clinical process. Psychoanalysis, as a developmental and personality theory, is much more closely linked to clinical practice than are other theories.

The final core assumption of psychoanalytic theory is that childhood experiences become structured into stable, enduring psychological processes. In other words, individuals are the product of their developmental experiences. Therefore, paying close attention to a variety of clinical data in the present (e.g., symptoms, dreams, fantasies, and patterns of behavior in relationships and in other contexts) enables the clinician to discern important features of childhood experiences that may only be partly remembered (if remembered at all) and only partly understood. Thus, an important goal of psychoanalytic clinicians is to better understand aspects of their clients’ past from the ways in which they operate in the present.

Key Elements of Psychodynamic Therapy

The dynamic unconscious, the role of defenses, and the developmental perspective are central to most schools of psychoanalytic treatment. They form a conceptual framework from which a psychodynamic therapist operates in an effort to understand a client’s concerns and to intervene constructively. In addition, all psychoanalytic schools of thought rely heavily on several other key concepts: free association, transference, countertransference, and the working alliance.

Free association refers to the “basic rule” of psychoanalysis, namely, that the client’s task is to say what comes to mind during therapy sessions as opposed to having an overly structured, goal-oriented approach. The assumption is that, like a fish net, material that is unconscious is always interconnected. Inviting clients to talk about whatever occurs to them without censoring their thoughts insures that conflictual or objectionable material that comes into consciousness will be spoken.

Transference refers, in a narrow sense, to the ways in which the therapeutic relationship is a re-creation of important prior relationships. Psychodynamic therapists assume that, via projection, clients re-create the relation-ship paradigms that governed their relationships with key attachment figures during the crucial period of childhood (especially over the first 5 or 6 years). A client who had a harsh and punitive father, for example, may come to believe that the therapist is judgmental and critical of the client. The client may misread the therapist’s reactions precisely because the client developed this schema for relationships in response to the harsh attitudes that were present and pervasive in earlier relationships. This history makes these same feelings, now projected onto the therapist, feel “real” in the therapeutic situation when, in fact, the therapist is working hard to be thoughtful and nonjudgmental.

Transference can be a rich means for understanding the effects of important relationships in the client’s past. As the therapist understands these past, formative relationships and conveys them to the client via interpretations, the client develops insight into how they are continuing to affect their present functioning. This allows clients to come to recognize how their experiences in their present relationships have been distorted by the influence of childhood experiences, and to change the way they relate to others.

Countertransference refers to the feelings that the therapist experiences within the therapeutic situation. Initially, Freud viewed countertransferencial feelings as obstacles to therapeutic progress that were derived from the therapists’ own unresolved neurotic conflicts. These unconscious conflicts were assumed to create blind spots in the therapist, making it difficult for the therapist to listen to or to clearly understand the client’s concerns. When protracted, such counter-transference feelings implied that the therapists needed to be in therapy to help them understand the source of the feelings that were interfering with their therapeutic effectiveness. In fact, historically, it was considered indispensable for a psychoanalytic therapist to have been in treatment as part of his training. Didactic psychotherapy would presumably help therapists experience and understand the issues and conflicts that might interfere with their effectiveness with their clients. Psychoanalytic institutes still require their candidates to be in analysis.

By the 1960s, psychoanalytic theorists had begun having reservations about this restrictive definition of countertransference. For one thing, it was acknowledged that it is common for therapists to have feelings about their clients and about the issues that their clients discuss in treatment. Furthermore, theorists had begun to understand that therapists’ feelings were often a rich source of information regarding what was occurring in therapy. Rather than view countertransference as an impediment to the therapeutic process, psychoanalytic therapists began using their countertransferential feelings as tools to help them engage with their clients more effectively, and as potential sources of information about the thoughts, feelings, and concerns which their clients were often unable to put into words.

This does not mean that all such feelings are constructive. On the contrary, it is still recognized that therapists’ unconscious conflicts may interfere with their therapeutic effectiveness and may play a destructive role when these are not understood. Nevertheless, countertransference is now viewed almost universally as a vital source of material for understanding what is going on within therapy.

The working alliance refers to the collaborative relationship that is established in therapy between the therapist and client. The alliance must be nurtured with care throughout the process of therapy, in part because therapy does not always make the client feel good. For example, exploring past experiences that are attached to deeply painful feelings requires sensitivity and tact on the part of the therapist. Trust between the therapist and client must be established if the client is to endure the painful elements of the process. Experiences that may cause the client to feel considerable shame or guilt may be playing a vital role in the client’s emotional life, but they may be the hardest things for the client to discuss in therapy precisely because of how they make the client feel. The working alliance helps the client feel safe enough to explore such difficult issues within the context of the therapeutic relationship, notwithstanding the fact that such an airing of thoughts, feelings, and experiences may temporarily make the client feel badly. It is also true, however, that for many clients there is a great deal of relief in the fact that the therapist is a warm, empathic person interested in the client’s concerns. This, too, reinforces the working alliance.

The working alliance is nurtured in several ways. One is via the therapist’s assuming a nonjudgmental stance toward the client’s material. This stance is related to Freud’s dictum that the therapist’s role is that of a blank screen, or of a well-polished mirror to reflect the client’s concerns. Similarly, Anna Freud described the therapist’s ideal position within the therapeutic situation as equidistant from the id, the ego, and the superego. Some of these suggestions have brought the criticism that psychoanalytic therapists are too detached. However, the intent is to direct therapists toward a neutral posture vis-a-vis their clients. This helps clients understand that their therapist is not going to respond judgmentally toward the experiences and feelings they bring into therapy.

Another way in which the working alliance is nurtured is through the creation of a stable, reliable therapeutic structure, also known as the frame, within which the therapy takes place. For example, psychoanalytic therapists tend to be mindful about beginning and ending sessions on time and about letting their clients know in advance about anticipated disruptions (e.g., vacations or other events) that mean that sessions will be cancelled. Generally speaking, psychoanalytic clinicians do not talk about themselves during appointments. For example, the focus remains on the client and the client’s life. Similarly, most psychoanalytic therapists do not take phone calls during appointments and in other ways take pains to prevent intrusions into their sessions. These steps are understood to safeguard the therapeutic situation and they alert the client to the fact that the therapist takes the work (and the client’s life) seriously. They help foster an understanding that the therapy and the therapeutic relationship exist as a stable process on which the client can rely. Strict adherence to confidentiality and to limiting therapist-client interactions to the therapy sessions also serve to create a therapy structure within which the client feels “held.” In short, the frame helps foster an experience of the treatment as a safe context, and of the therapist as a reliable ally.

No review of psychoanalytically informed therapies would be complete without a discussion of dream interpretation. Freud considered dreams to be the royal road to the unconscious, and in the early years of psycho-analysis clinicians and their clients often devoted multiple sessions to a concerted effort to decode the meaning of a single dream. Contemporary therapists are less likely to spend as much time on a single dream as they did in Freud’s day, although the meaning of a particular dream may be clarified over the course of further work. However, the view that dreams are an important source of information about the client’s unconscious remains central. Freud viewed the content of dreams as standing on two legs: the present and the past. From the present a dreamer might draw from a day residue—that is, feelings, images, and situations that the dreamer has been negotiating at the moment. The dream also draws upon the past, from the organizing conflicts with which the dreamer continues to struggle.

Typically, the client is asked to free-associate (i.e., say what comes to mind spontaneously) about the different images, themes, feelings, or situations that appear in the dream. Freud was adamant that a dream could not be understood without the dreamer’s associations. He eschewed cookbook approaches to dream interpretation in which specific images might be automatically understood as linked to specific contents. The therapist attempts to make sense of the dream in relation to these associations and in relation to what the therapist has learned about the client over the course of the treatment.

Psychoanalytic notions of helpful interventions tend to revolve around two key ideas: the role of insight in therapy and the role of the therapeutic relationship as a curative agent. Insight was considered to be the lynchpin of therapeutic cure throughout the formative years of psychoanalytic theorizing. Freud’s initial formulations relied on an understanding of traumatic experiences that were theorized to be unconscious (and maintained there by repression and other defenses), so gaining insight (i.e., making these unconscious memories, feelings, and anxieties conscious) was seen as a central component of the therapeutic cure. While it is often assumed that insight is an intellectualized process, Freud emphasized that an intellectual understanding, devoid of feelings and emotional engagement, was not sufficient to help clients resolve their concerns.

The role of insight in therapeutic process led psychoanalysts and psychodynamic therapists to place great importance on the role of interpretation in helping clients to resolve their emotional conflicts. Interpretation is a technical term for a therapist’s formulation, offered to the client during the therapeutic process, of how a client is unconsciously defending against thoughts, feelings, and impulses, or of what it is that the client is defending against. In other words, an interpretation is the means by which therapists attempt to help clients better understand themselves. This perspective is seated, more broadly, in values such as the value of knowing oneself and of being honest with oneself and others. Thus, insight, and the process of better understanding the forces that have shaped one’s emotional life, is a key component in the psychoanalytic process.

More recently, the importance of the therapeutic relationship itself, rather than insight alone, has become an increasingly central construct for understanding how it is that therapists help their clients resolve their concerns. Psychodynamic therapists, especially those from the relational and interpersonal schools, now give greater weight to the working alliance. The interaction that occurs in the interpersonal field between the therapist and client can become a rich source of material for understanding how the client engages the world and a rich context within which to resolve their concerns. This is especially true if the therapeutic relationship is one in which the therapist is empathically attuned and skillful in using the relationship to understand the client’s issues. Learning about healthier forms of engagement within the therapeutic relationship often translates into healthier relationships in clients’ lives outside of the consulting room.

References:

  1. Ellman, S. (2002). Freud’s technique papers: A contemporary perspective. New York: Other Press.
  2. Greenberg, J., & Mitchell, G. (1983). Object relations in psychoanalytic theory. Cambridge, MA: Harvard University Press.
  3. Levy, S. (1984). Principles of interpretation. New York: Jason Aronson.
  4. McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. New York: Guilford Press.
  5. McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. New York: Guilford Press.
  6. Pine, F. (1985). Developmental theory and clinical process. New Haven, CT: Yale University Press.
  7. Pine, F. (1990). Drive, ego, object, and self. New York: Basic Books.

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