Current psychotherapies
Chapter 2
Psychoanalytical psychotherapies

Introduction

Psychoanalysis is a distinctive form of psychological treatment, and a model of psychological functioning, human development, and psychopathology. There is a host of different theories and treatment models that have developed over more than a century.

Certain basic principles that tend to cut across different psychoanalytic perspectives are 1) an assumption that all human beings are motivated in part by wishes, fantasies, or tactic knowledge that is outside of awareness (unconscious motivation), 2) an interest in facilitating awareness of unconscious motivations, thereby increasing choice, 3) an emphasis on exploring the ways in which we avoid painful or threatening feelings, fantasies, and thoughts, 4) an assumption that we are ambivalent about changing and an emphasis on the importance of exploring this ambivalence, 5) an emphasis on using the therapeutic relationship as an area for exploring clients’ self-defeating psychological processes and actions (both conscious and unconscious), 6) an emphasis on using the therapeutic relationship as an important vehicle of change, 7) an emphasis on helping clients to understand the way in which their own construction of their past and present plays a role in perpetuating their self-defeating patterns.

Basic concepts

The unconscious

Rational understanding of the factors motivating our actions often proves inadequate. The unconscious is an area of physic functioning in which impulses and wishes, as well as certain memories, are split off from awareness. This occurs either because the associated affects are too threatening or because the content of the impulses and wishes themselves are learned by the individual to be unacceptable through cultural conditioning.

Many contemporary psychoanalysis no longer conceptualize the unconscious in precisely the same way that Freud did. Some still content that there is a hypothetical psychic agency that keeps aspects of experience deriving from the more primitive, instinctually based aspect of the psyche out of awareness. Others argue that it is problematic to speculate about the nature of hypothetical psychic agencies.

Common threads through the differing perspectives are the premises that our experience and actions are influenced by psychological processes that are not part of our conscious awareness and these unconscious processes are kept out of awareness in order to avoid psychological pain.

Fantasy

People’s fantasies play an important role in their psychic functioning and the way in which they relate to external experience, especially their relationships with other people. These fantasies vary in the extent to which they are part of conscious awareness, ranging from daydreams and fleeting fantasies of the edge of awareness to deeply unconscious fantasies that trigger psychological defences. Fantasy serves a number of psychic functions, including the need for regulation of self-esteem, the need for a feeling of safety, the need for regulating affect, and the need to master trauma.

because fantasies are viewed as motivating our behaviour and shaping our experience, exploring and interpreting clients’ fantasies is viewed as an important part of the psychoanalytic process.

Primary and secondary processes

Primary process is a raw or primitive form of psychic functioning that begins at birth and continues to operate unconsciously throughout the lifetime. In primary process, there is not distinction between past, present and future. Different feelings and experiences can be condensed together into one image of symbol, feelings can be expressed metaphorically, and the identities of different people can be merged. Primary processes can be seen operating throughout childhood and adulthood in dreams and fantasy, as well as more consistently in individuals suffering from acute psychosis.  

Secondary process is the style of psychic functioning associated with consciousness. It is logical, sequential and orderly, and the foundation for rational, reflective thinking.

Defenses

A defense is an intra-psychic process that functions to avoid emotional pain by pushing thoughts, wishes, feelings, or fantasies out of awareness. These are: 1) Intellectualization, an individual talks about something threatening while keeping an emotional distance from the feelings associated with it. 2) Projection, a person attributes a threatening feeling or motive he is experiencing to another person. 3) Reaction formation, someone denies a threatening feelings and proclaims he feels the opposite. 4) Splitting, an individual attempts to avoid his or her perception of the other as good from being contaminated by negative feelings or he or she may split the representation of the other into two different images.

Splitting may be commonly used by infants so that they are able to feel safe with their mother. The ability to integrate the good and bad representations of the mother might be a developmental achievement that requires the ability to tolerate ambivalent feelings about the mother. Clients who have more severe psychological disturbances might never achieve this ability as adults, so the client experiences dramatic fluctuations in his or her perceptions and feelings toward others.

Transference

Freud observed that it was not uncommon for clients to view him and relate to him in ways that were reminiscent of the way they viewed and related to significant figures in their childhood. They were ‘transferring’ a template from the past onto the present situation.

The development of transference is an indispensable part of the psychoanalytic process. By reliving the past in the analytic relationship, the client provides the therapist with an opportunity to help him develop an understanding of how past relationships were influencing the experience of the present in an emotionally immediate way.

One- versus two-person psychologies

Two-person psychology is a perspective in which therapist and client are viewed as co-participants who engage in an ongoing process of mutual influence at both conscious and unconscious levels. This implies that the therapist cannot develop an accurate understanding of the client without developing some awareness of her own ongoing contribution to the interaction.

Other systems

One difficulty with comparing psychoanalysis to other systems of psychotherapy is that psychoanalysis is not just form of therapy, it is a worldview.

Reasons for the declining fortunes of psychoanalysis are: the tendency for psychiatry to become increasingly biological, the rise of the cognitive-behavioural tradition and growing emphasis on evidence-based treatment, a negative public reaction to an attitude of arrogance, insularity, and elitism that came to be associated with the psychoanalytic tradition, and psychoanalysis have been guilty of a lack of receptiveness to valid criticism and empirical research. Many of these problems emerged as a result of various historical, cultural and social-political forces that shaped the development of psychoanalysis, but are not intrinsic to it.

Many of these problematic features of psychoanalysis have diminished in the last two decades as a result of internal reforms and modifications that have taken place within the psychoanalytic tradition. Many people on the broader mental-health field and the general public are unaware of these changes.

The current marginalization of psychoanalysis is attributable not only to valid criticism but also to the unhealthy contemporary cultural biases.

History

Precursors

Freud’s development of psychoanalytic theory and practice was influenced by a number of cultural and intellectual trends and scientific models that dominated European circles in the late 19^th and early 20^th centuries. Two of these influences were exposure to developments in French neurology and psychiatry that explored the role that the splitting of conscious played in psychopathology, and a collaboration with Breuer, who talked with clients.

Freud came to believe that hysterical symptoms were the result of suppressed emotions that had been cut off at the time of trauma, and that these emotions expressed themselves in the form of physical symptoms.

Beginnings

Freud encouraged clients to ‘say everything that comes to mind without censoring’, which was the origin of free association. Free association is a technique in which clients are encouraged to attempt to suspend their self-critical function and verbalize thoughts, images, associations, and feelings that are on the edge of awareness.

There was an evolving conception of the goals of psychoanalysis. One of the important goals of psychoanalysis involved the pursuit of truth.

From seduction theory to drive theory

Seduction theory means that sexual trauma always lies at the root of psychological problems. Over time, Freud abandoned this theory and began to focus on the role that sexual instincts play in the developmental process. He theorized that rudimentary sexual feelings are present even during early infancy and give rise to sexually related wishes and fantasies that are pushed out of consciousness because they were experienced as too threatening. Often the recovered memories of sexual trauma are actually the product of reconstructed fantasies rather than real sexual trauma.

Freud’s growing emphasis on unconscious fantasy opened the way to a deeper appreciation of the complex nature of psychic life that was not always obvious to the everyday observer. His evolving perspective involved tracing the chain of the client’s associations in order to help formulate hypotheses about childhood fantasies and wishes that had been covered over and disguised.

Freud came to believe that all thinking and action were fuelled by a type of psychic energy that is linked in a complex way to sexuality. He developed a motivational model that held that psychic energy (libido) could be activated by both external and internal stimuli, which in turn produces an organismic sense of tension or ‘unpleasure’. Maintaining psychic energy at a constant level was biological imperative. Once psychic energy became activated it needed to be discharged, which restored psychic equilibrium and was experienced as pleasure. This could take place in a variety of ways. The psychobiological push to repeat experiences that become associated with tension reduction is the pleasure principle. The general model of motivation is known as drive theory.

Freud theorized that the process of psychological development was linked to the biological process of sexual development (psychosexual theory).

The trend within today’s psychoanalysis is to replace psychosexual theory with a model of motivation that is more consistent with contemporary developments in emotion theory and research and the affective neurosciences.

Jung, Bleuler, and the Zuric psychoanalytic society

Bleuler and Jung accounted findings using Freud’s theories about the nature of consciousness. Jung’s published articles were well received by the mainstream psychiatric community. At the same time, a number of psychiatrists at the Burgholzli clinic began to experiment with the use of treatment methods that they had gleaned from Freud’s writings.

The development of structural theory and ego psychology

Structural theory distinguish between three psychic agencies. These are : 1) Id, the aspect of the psyche that is intrinsically based and present from birth. It presses for immediate sexual gratification. 2) Ego, which gradually emerges out of the id and functions to represent the concerns of reality. The ego evaluates the suitability of the situation for satisfying one’s instinctual desires, and it allows the individual to delay instinctual gratification or find other ways of channelling instinctual needs in a socially acceptable form. It mediates between the demands of the id and the superego.3) Superego, the psychic agency that emerges through the internalization of social values and norms. Some are conscious, others not.

One goal of analysis traditionally has been to help individuals become more aware of the overly harsh nature of their superegos so that they become less self-punitive.

The development of object relations theory in Britain

Object relations theory in concerned with the way in which we develop internal representations of our relationships with significant others.

The British system has formally institutionalized the existence of three different psychoanalytic traditions.

Current status

Toward psychoanalytic pluralism in North America

The US formally recognized the existence of only one psychoanalytic tradition. Ego psychology centred firmly around Freud’s structural theory later refinements.

American ego psychology gradually consolidated into an orthodoxy that is classical psychoanalysis. Classical psychoanalysis was characterized by an adherence to certain core theoretical premises as well as specific technical guidelines. The core theoretical premises included an adherence to Freud’s drive theory of motivation and to his psychosexual model of development.

Classical psychoanalysis viewed transference as a projection of the client’s unconscious dynamics. The key mechanism of change was theorized to involve the process of gaining insight into one’s own unconscious conflicts.

Technical guidelines specified that therapists should: strive to maintain anonymity, attempt to remain neutral and avoid gratifying the client’s immediate wishes.

Theorists diverging too far from mainstream ego psychology tended to become marginalized. In some cases, they started their own school of thought. Two of these are Interpersonal psychoanalysis (It is impossible to understand the individual apart from the context of relations with others) and relational psychoanalysis (placed emphasis on the instinctual need for human relatedness).

The culture created a fertile climate for changes within the psychoanalytic world.

Contemporary ego psychology had involved into modern conflict theory. Conflict theory emphasizes the centrality in human experience and the action of ongoing conflict between unconscious wishes and defences against them. There is a more pragmatic emphasis on principles of technique and practice, and there are efforts to develop an overarching model of the human psyche.

Kleinian and Lacanian traditions in Europe and Latin America

Lacanian argued the our identity is forged out of a misidentification of ourselves with the desire of the other. There is a lack from the self, and this stems from the fact that our experience cannot be communicated without the medium of language. The processes of symbolizing our experience through language results in a distortion of this experience.

Personality

There is no one psychoanalytic theory of personality.

Theories of personality

Conflict theory

Beginning with Freud, intra-psychic conflict has been viewed as playing a central role in the development of the individual’s specific personality. Different personality or character styles can be understood as resulting from the compromise between specific underlying core wishes and characteristic styles of defence that are used to manage these wishes.

Object relations theory

Object relations perspectives on personality theorize that internal representations influence the way in which people perceive others, choose particular types of people with whom to establish relationships, and shape their relationships in an ongoing fashion through their own perceptions and actions.

Attachment theory is a model of object relations. To maintain proximity to the attachment figure, infants develop representations of their interactions with their attachment figures that allow them to predict what type of actions will increase the possibility of maintaining proximity.

Object relations theory assumes that internal models are shaped by a combination of these real experiences with unconscious wishes and fantasies and other intra-psychic processes that are not reality based. ­

Klein theorized that people are born with instinctual passion related to both love and aggression and that are linked to unconscious fantasies and images about relationships with others. These exists before any actual encounter and serve as the scaffolding for the perception of others. Klein believed that infants experience their own aggression as intolerable, and therefore need to fantasize that this aggression originates in the other. Projective identification is the intra-psychic process through which feelings that originate internally are experienced as originating from the other. The unconscious fantasies are internal objects. To retain some perception of the other as potentially good, infants unconsciously split the image of the other.

Fairbairn theorizes that internal objects are established when the individual withdraws from external reality and create a type of internal reality as a substitute. These fantasized relationships become important building blocks for one’s experience of the self because the self is always experienced in relationship to others. But, attempts to control significant others by developing fantasized relationships with them, rather than real ones, are only partially successful.

Developmental arrest models

Developmental arrest models theorize that psychological problems emerge as a result of the failure of caregivers to provide a ‘good enough’ or optimal environment. As a result, the normal developmental process becomes arrested.

The infant begins in a state of omnipotence, believing that her or his wishes make things happen and that the mother will satisfy all of his or her needs. Over time, the mother will fail the infant, and the infant begins to lose her or his experience of omnipotence and to experience a distinction between his or her reality and fantasies. If the mother is too unresponsive, the infant will become overadapted to the needs of the other and develop a false self. The infant might grow up to feel alienated from himself, resulting from the subjective experience of lack of inner vitality. If the process by which the infant’s sense of omnipotence is frustrated takes place in a sufficiently gradual fashion, the infant can come to accept the limitations of the other without being traumatized.

To develop a cohesive sense of self, the developing child requires caregivers who are able to provide adequate mirroring or attunement to his or her needs.

Psychotherapy

Theory of psychotherapy

What is psychoanalytic theory?

Psychoanalysis is a form of treatment with certain defining characteristics. Psychodynamic therapy are forms of treatment that are based on psychoanalytic theory but lack some of the defining characteristics of psychoanalysis.

Psychoanalysis is long term, intensive, and open ended. It is characterised by a specific therapeutic stance that involves 1) an emphasis on helping clients to become aware of their unconscious motivation. 2) Refraining from giving the client advice or being overly directive. 3) Attempting to avoid influencing the client by introducing one’s own belief and values. 4) Maintaining a certain degree of anonymity by reducing the amount of information one provides about one’s personal life or one’s feeling and reactions in the session. 5) Attempting to maintain the stance of the neutral and objective observer. 6) A seating arrangement in which the client reclines on a couch and the therapist sits upright and out of view of the client.

Many psychoanalysis no longer make such rigid distinctions between psychoanalysis and psychoanalytic treatment.

The therapeutic alliance

Freud emphasized the importance of establishing a good collaborative relationship with the client. Greenson emphasized that the caring, human aspects of the therapeutic relationship play a critical role in allowing the client to benefit from psychoanalysis. According to Bordin, the strength of the alliance depends on how much the client and therapist agree about the tasks and goals of therapy and on the quality of the relational bond between them. The tasks of therapy consists of the specific activities that the client must engage in to benefit from treatment. The goals of therapy are general objectives toward which the treatment is directed. The bond refers to the degree of trust the client has in the therapist and the extent to which he or she feels understood. Bond, task, and goal components of the alliance influence each other.

Transference

Transference is the client’s tendency to view the therapist in terms that are shaped by his or her experiences with important caregivers and other significant figures who played important roles during developmental processes. Early experiences establish schemas that shape the perception of people in the present.

The therapeutic relationship provides an opportunity for the client to bring the memory of the relationship with the parent from the past to life through the relationship with the therapist. This provides the therapist with an opportunity to help clients gain insight into how their experiences with significant figures in the past have resulted in unresolved conflicts that influence their current relationships.

Countertransference

The therapist’s countertransference is the totality of his or her reactions to the client. It can be useful therapeutically, but is not without potential dangers.

Resistance

Resistance is the tendency for an individual to resist change or act in a way that undermines the therapeutic process. It is the way in which defensive processes manifest in the therapy session and interfere with the therapist’s goals or agenda. Emphasis has been placed on the self-protective aspects of resistance.

Inter-subjectivity

As the two-person psychology perspective grows in influence, some analytic thinkers find that conceptualizing the psychotherapy situation in terms of the client’s perspective and the therapist’s perspective is incomplete. The meeting of two minds is thought to produce a new, emergent product, the analytic dyad. Understanding in psychotherapy derives out of the dialogue between therapist and client through which meaning is constructed.

Mitchell says that this processes allows the client to gradually learn that human relationships are flexible, and that it is possible to recognize the potential validity of the other persons’ perspective without feeling demolished or invalidated.

Pizer describes the therapy session as an ongoing negotiation about the meaning of substance reality.

It is conceptualized that transference-countertransference can be understood in terms of an ongoing implicit and explicit negotiation about what is taking place in the therapeutic relationship. This might play a role in helping the client develop the capacity for inter-subjectivity. This is the ability to hold onto one’s own experience while at the same time beginning to experience the other as an independent centre of subjectivity.

Enactment

Because client and therapist are always influencing one another at both conscious and unconscious levels, they inevitably end up playing complementary roles in relational scenarios of which neither is fully aware. Both client’s and therapist’s relational schemas will influence these scenarios. The process of collaborating in the exploration of how each of them is contributing to these scenarios provides clients with an opportunity to see how their own relational schemas contribute to the enactment, and for playing out new scenarios with other persons, contributing to a modification of their current schemas.

We are influenced by complex nonverbal communications from others that are difficult to decode and humans are never fully transparent to themselves.

Process of psychotherapy

Empathy

The most fundamental intervention is empathy. The ability to identify with our clients and immerse ourselves in their experience is critical in the process of establishing an alliance, it is a central mechanism of change and of itself.

Interpretation

An interpretation has traditionally been conceptualized as the therapist’s attempt to help clients become aware of aspects of their inter-psychic experience and relational patterns that are unconscious. It is the therapist’s attempt to convey information that is outside of the client’s awareness.

The accuracy of an interpretation is the extent to which an interpretation corresponds with a ‘real’ aspect of the client’s unconscious functioning. The quality or usefulness of an interpretation is the sense that the client can make use of the interpretation as part of the change process. Three aspects of this are timing, depth and empathic quality.

Clarification, support and advice

Many contemporary psychoanalytic therapists find that support, reassurance, and advice can play vitally important roles in the change process. A willingness on the therapist’s part to give advice, especially when asked for it, is consistent with reducing the power imbalance because we are ‘playing our cards straight up’.

Termination

A well-handled termination can play a vital role in helping clients consolidate any gains that have been made. Poorly handled terminations can negatively affect the treatment process.

Ideally, the decision to terminate is made collaboratively by client and therapist and marks the end of a treatment that has been helpful and satisfying.

The therapist needs to strike a balance between on one hand trying too hard to hold on to a client who wants to terminate, and on the other, failing to adequately explore the client’s underlying motivations for terminating.

When the process of exploring the client’s desire to leave treatment does lead to a final decision to terminate, it is useful to establish a contract to meet for a certain number of final sessions and thus provide an opportunity to terminate in a constructive fashion.

Mechanisms of psychotherapy

Making the unconscious conscious

Change often involves making the unconscious conscious. Changes involves becoming aware of our instinctual impulses and related unconscious wishes and then learning to deal with them in a rational or reflective fashion. By becoming aware of our unconscious wishes and our defences against them, we increase the degree of choice available to us.

Emotional insight

The primary vehicle for making the unconscious conscious is through the use of verbal interpretations that give the client insight into the unconscious factors that are shaping his or her experience and actions. Emotional insight is combining the conceptual with the affective so that the client’s new understanding has an emotionally immediate quality to it and is not relegated to the realm of intellectual understanding that has no impact on his or her daily functioning.

One of the key ways of increasing the possibility that the insight will be emotional is through the use of transference interpretations that lead the client to reflect on his or her immediate experience of the therapeutic relationship.

Creating meaning and historical reconstruction

People often come to therapy with varying degrees of difficulty in the construction of meaningful narratives about their lives.

Psychoanalytic practice provides culturally normative psychological or psychoanalytic explanations for symptoms and emotional pain. It adds an additional dimension of creating meaning through a process of co-constructing an idiosyncratic narrative that is tailored to the client’s unique history and psychology.

The process of constructing a viable narrative account of the role that one’s childhood experiences played in contributing one’s problems can decrease the experience of self-blame.

The process of exploring and clarifying one’s own values and engaging in a meaningful dialogue with the therapist can help clients reorient themselves and develop a more refined sense of what is meaningful to them. This often involves becoming more aware of and articulating the nuances of one’s emotional experience in the context of the relationship with the therapist.

Increasing and appreciating the limits of agency

As clients gain a greater appreciation of the connections between their symptoms, their way of being, and their own contributions to conflictual patterns, they come to experience a greater degree of choice in their lives and experience themselves as agents rather than victims. This growing awareness must be experientially based. The client must also come to appreciate and accept the limits of agency.

Containment

Containment involves attending to our own emotions when working with clients and cultivating the ability to tolerate and process painful or disturbing feelings in a non-defensive fashion.

Children and clients imagine that unacceptable feelings belong to the caregiver or therapist, and they exert subtle pressures that evoke the dissociated feeling in the other. Children need their parents to help them process raw emotional experience and learn to tolerate, symbolize, and make sense of the experience.

Rupture and repair

An ongoing process of interactive disruption and repair in infant and mother communication, plays an important role in the normal developmental process by helping the infant develop a form of implicit relational knowing that represents both the self and other as capable of repairing disruptions in relatedness.

The therapist’s inevitable failures provide opportunities for working through in a way that helps the client to begin to bring him or herself into the relationship in a way that is experienced as real.

Applications

Who can we help?

Psychoanalysis (when conceptualized in a rigid fashion) is most appropriate for clients who are neurotic, who have a relatively high level of ego strength and cohesiveness, and the capacity for self-reflection.
When conceptualized more flexible it can be useful to a wide range of clients.