38.2: Psychoanalysis And Psychodynamic Therapy

The earliest organized therapy for mental disorders was psychoanalysis. Made famous in the early twentieth century by one of the best-known clinicians of all time, Sigmund Freud, this approach stresses that mental health problems are rooted in unconscious conflicts and desires. In order to resolve the mental illness, then, these unconscious struggles must be identified and addressed. Psychoanalysis often does this through exploring one’s early childhood experiences that may have continuing repercussions on one’s mental health in the present and later in life. Psychoanalysis is an intensive, long- term approach in which patients and therapists may meet multiple times per week, often for many years.

History of Psychoanalytic Therapy

Freud initially suggested that mental health problems arise from efforts to push inappropriate sexual urges out of conscious awareness (Freud, 1895/1955). Later, Freud suggested more generally that psychiatric problems are the result of tension between different parts of the mind: the id, the super- ego, and the ego. In Freud’s structural model, the id represents pleasure-driven unconscious urges (e.g., our animalistic desires for sex and aggression), while the superego is the semi-conscious part of the mind where morals and societal judgment are internalized (e.g., the part of you that automatically knows how society expects you to behave). The ego— also partly conscious—mediates between the id and superego. Freud believed that bringing unconscious struggles like these (where the id demands one thing and the superego another) into conscious awareness would relieve the stress of the conflict (Freud, 1920/1955)—which became the goal of psychoanalytic therapy.

Although psychoanalysis is still practiced today, it has largely been replaced by the more broadly defined psychodynamic therapy. This latter approach has the same basic tenets as psychoanalysis but is briefer, makes more of an effort to put clients in their social and interpersonal context, and focuses more on relieving psychological distress than on changing the person.

Techniques in Psychoanalysis

Psychoanalysts and psychodynamic therapists employ several techniques to explore a patient’s unconscious mind. One common technique is called free association. Here, the patient shares any and all thoughts that come to mind, with- out attempting to organize or censor them in any way. For example, if you took a pen and paper and just wrote down whatever came into your head, letting one thought lead to the next without allowing conscious criticism to shape what you were writing, you would be doing free association. The analyst then uses his or her expertise to discern patterns or underlying meaning in the patient’s thoughts.

Figure \(\PageIndex{1}\): Sigmund Freud. Building on the work of Josef Breuer and others, Freud developed psychotherapeutic theories and techniques that became widely known as psychoanalysis or psychoanalytic therapy. [“Sigmund Freud 1926” by Ferdinand Schmutzer/Wikimedia Commons is in the public domain.]

Sometimes, free association exercises are applied specifically to childhood recollections. That is, psychoanalysts believe a person’s childhood relationships with caregivers often determine the way that person relates to others, and predicts later psychiatric difficulties. Thus, exploring these childhood memories, through free association or otherwise, can provide therapists with insights into a patient’s psycho- logical makeup.

Because we don’t always have the ability to consciously recall these deep memories, psychoanalysts also discuss their patients’ dreams. In Freudian theory, dreams contain not only manifest (or literal) content, but also latent (or symbolic) con- tent (Freud, 1900/1955). For example, someone may have a dream that his/her teeth are falling out—the manifest or actual content of the dream. However, dreaming that one’s teeth are falling out could be a reflection of the person’s unconscious concern about losing his or her physical attractiveness—the latent or metaphorical content of the dream. It is the therapist’s job to help discover the latent content underlying one’s manifest content through dream analysis.

In psychoanalytic and psychodynamic therapy, the therapist plays a receptive role—interpreting the patient’s thoughts and behavior based on clinical experience and psychoanalytic theory. For example, if during therapy a patient begins to express unjustified anger toward the therapist, the therapist may recognize this as an act of transference. That is, the patient may be displacing feelings for people in his or her life (e.g., anger toward a parent) onto the therapist. At the same time, though, the therapist has to be aware of his or her own thoughts and emotions, for, in a related process called countertransference, the therapist may displace his/her own emotions onto the patient.

The key to psychoanalytic theory is to have patients uncover the buried, conflicting content of their mind, and therapists use various tactics—such as seating patients to face away from them—to promote a freer self-disclosure. And, as a therapist spends more time with a patient, the therapist can come to view his or her relationship with the patient as another reflection of the patient’s mind.

Advantages and Disadvantages of Psychoanalytic Therapy

Psychoanalysis was once the only type of psychotherapy available, but presently the number of therapists practicing this approach is decreasing around the world. Psychoanalysis is not appropriate for some types of patients, including those with severe psychopathology or intellectual disability. Further, psychoanalysis is often expensive because treatment usually lasts many years. Still, some patients and therapists find the prolonged and detailed analysis very rewarding.

Perhaps the greatest disadvantage of psychoanalysis and related approaches is the lack of empirical support for their effectiveness. The limited research that has been conducted on these treatments suggests that they do not reliably lead to better mental health outcomes (e.g., Driessen et al., 2010). And, although there are some reviews that seem to indicate that long-term psychodynamic therapies might be beneficial (e.g., Leichsenring & Rabung, 2008). other researchers have questioned the validity of these reviews. Nevertheless, psychoanalytic theory was history’s first attempt at formal treatment of mental illness, setting the stage for the more modern approaches used today.