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3.7: Psychoanalysis

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    16349
  • Most psychologists today make a distinction that Freud seldom, if ever, made. We refer to all theoretical perspectives related to the views of Sigmund Freud as psychodynamic theories, reserving the term psychoanalysis for the therapeutic method developed by Freud. Freud simply referred to both his theories and his therapy as psychoanalysis. This may well have resulted from the fact that Freud began as a therapist, and only developed his theories in order to explain why certain approaches worked and others did not. It may also have something to do with the fact that Freud’s personality theories came first, and so there was no need in his mind to distinguish his views from the work of others. Whatever the reason, for our purposes we will use the term psychoanalysis to refer to the therapeutic method developed by Freud, which was uniquely different from the techniques already in use by people such as Breuer and Charcot. I would also like to note that many of the references in this section cite the book co-authored by Freud and Breuer (1895/2004). However, the citations come from a portion of the book written by Freud alone, and in which he takes personal credit for the work. Therefore, we need to acknowledge that although the book is published as the work of both men, it contains mostly each man’s individual work, and only the “Preliminary Statement” is co-authored by Freud and Breuer. This point is by no means a small one, because it was at this point in their careers that the two men went their separate ways.

    As mentioned above, Freud came to believe that the use of hypnosis, which had been championed by Breuer and Charcot, was unable to get at the root causes of patient’s neuroses. He also learned through experience that psychoanalysis could only be effective if he was able to go back into the early childhood of his patients and uncover the unconscious conflicts and repressions that led to their neurotic behaviors. In order to accomplish this goal, Freud relied primarily on free association and dream analysis. In the history of psychoanalysis, there have been those who believed that psychoanalysis officially began when Freud rejected hypnosis and introduced free association (Freud, 1914/1995). Free association is often used, of course, during the interpretation of dreams, so the two techniques are not mutually exclusive. With regard to the value of interpreting dreams, Freud wrote perhaps his most famous line: “…the interpretation of dreams is the via regia [royal road] to a knowledge of the unconscious element in our psychic life.” (pg. 508; Freud, 1900/1995).

    Free Association – Freud’s Therapeutic Breakthrough

    Free association grew out of a need that resulted from problems implementing Breuer’s cathartic method. The first problem was that many patients could not be hypnotized. With the patients that Freud could not hypnotize, especially those who would not even allow him to try hypnotizing them, Freud tried a technique of pressing them to remember. This technique also came up short, and Freud recognized a need to work around the patient’s resistance (which we will examine in more detail below). The first technique that Freud developed involved pressing his hand against his patient’s forehead and asking them to say whatever thought, no matter how seemingly irrelevant, came first into their consciousness (Freud & Breuer, 1895/2004). Freud himself described this technique as a trick, one that disconnects the patient’s attention from his conscious searching and reflecting. However, trick or not, Freud found the technique to be indispensable. The thoughts that came to the forefront of consciousness, those believed to be easily accessible via the preconscious, were likely to be connected to the underlying associations responsible for the neurotic patient’s symptoms. Freud used this technique of free association quite successfully. As early as 1892, he treated a patient known as Fräulein Elisabeth von R. by relying entirely on free association (Freud & Breuer, 1895/2004).

    Still, Freud did make some modifications in the technique. Two other methods used to begin the free association were to have the patient think of a number or a name at random. Of course, Freud did not believe that it was possible for anything in the mind to occur at random, and by continuing the association brought up by that first name or number, Freud could help his patient to arrive at the true unconscious associations that were the root of their problems (Freud, 1917/1966). He also used free association during the interpretation of dreams, and often found it helpful to examine which part of the dream the patient chose to begin making free associations (Freud, 1933/1965). Freud also considered psychoanalysis to be effective with children, but cautioned that a child’s lack of psychological development limited their ability for free association. Other psychodynamic theorists worked more extensively with children, however, including Adler, Anna Freud, and Klein.

    The Elements of Dream Analysis

    For someone who considered dreams to be the royal road to the unconscious mind, it is no surprise that Freud’s first book of his own was The Interpretation of Dreams (Freud, 1900/1995). The value of this work never diminished, and Freud devoted a chapter to dream interpretation in one of his last books: An Outline of Psycho-Analysis (Freud, 1938/1949). In the latter book, published only a year before Freud died, he wrote:

    The only thing that can help us are states of conflict and uproar, when the contents of the unconscious id have a prospect of forcing their way into the ego and into consciousness and the ego puts itself once more on the defensive against this invasion. …Now, our nightly sleep is precisely a state of this sort, and for that reason psychical activity during sleep, which we perceive as dreams, is our most favourable object of study. In that way, too, we avoid the familiar reproach that we base our constructions of normal mental life on pathological findings; for dreams are regular events in the life of a normal person… (pg. 38)

    Freud described our recollection of a dream as a façade, a covering that hides the underlying process of the dream. Thus, a dream has both manifest content and latent content. The manifest content (or the dream-content) of a dream is what we actually remember when we wake up. The latent content (or the dream-thoughts), however, is the true underlying meaning of the dream, the unconscious material from the id desiring satisfaction. Freud described the process by which the latent content is transformed into the manifest content as the dream-work (Freud, 1900/1995). Studying the nature of the dream-work, the way in which the unconscious material from the id forces its way into the ego but is transformed by the ego’s opposition to the impulse, allows us to understand what is known as dream-distortion (Freud, 1938/1949). The importance of dream-distortion becomes clear when we consider the purpose of dreams. Freud believed that all dreams represent our true desires. Therefore, all dreams can be viewed as wish fulfillment. Although some dreams can be very anxiety-provoking, and certainly do not seem to represent our wishes and desires, this is the result of the distortion. If we successfully analyze the dream and identify its latent content, then Freud believed we would recognize the true wish-fulfillment nature of even anxiety-provoking or frightening dreams (Freud, 1900/1995).

    When we sleep, the ability of the ego to repress or otherwise redirect the unacceptable impulses of the id is paralyzed. The id, then, is afforded “a harmless amount of liberty” (Freud, 1938/1949). But the ego is still the seat of consciousness, and still exerts some influence over the expression of the id impulses. And so the dream is distorted, transformed into something less threatening to the ego, particularly into something not threatening enough to wake the person up. To summarize this situation, when we are asleep the ego is less able to restrain the id. Consequently, the impulses of the id intrude in the preconscious and then into the conscious mind. This provokes anxiety and threatens to wake us up. However, the dream transforms the id impulse into the fulfillment of a wish, and we are able to continue sleeping. As Freud described it:

    We shall be taking every experience into account if we say that a dream is invariably an attempt to get rid of a disturbance of sleep by means of a wish-fulfillment, so that the dream is a guardian of sleep. (pg. 46; Freud, 1938/1949)

    Does it seem reasonable to say that all dreams are wish fulfillment? Certainly some dreams clearly fulfill our wishes and desires, at least through fantasy. Such dreams do not require any analysis. Other dreams, however, seem to make no sense at all. The id and the unconscious mind are not logical at all, contradictory ideas easily coexist side by side, and Freud even referred to the unconscious mind as the “Realm of the Illogical” (pg. 43; Freud 1938/1949). As these latent impulses are transformed into manifest content, it can be very difficult to separate them and make sense of a given dream. The dream-work itself, the very process of distorting or transforming the latent content into the manifest content in order to disguise the meaning of our dreams, involves a variety of factors, including: condensation, displacement, the use of symbolic representation, and secondary elaboration (Freud, 1900/1995).

    According to Freud, condensation refers to the tendency to create unity out of a variety of dream elements that we would keep separate if we were awake. So, a single element of the manifest content of a dream might represent a number of latent thoughts. Thus, the analysis of a dream could be much longer than the dream itself. Displacement is not unrelated to condensation according to Freud, and refers to the switching of libidinal energy from one object to another, such that the important object of a dream might seem inconsequential, and vice versa. In other words, the apparent focus of the dream is probably not the actual focus of the dream. This does not simply suggest that we might substitute one person for another in a dream, it also happens that we might represent various elements through symbols. Once again, these symbols are employed by dreams to disguise the representation of latent content. As important as Freud considered symbols to be in a dream, he did not support the idea that dream dictionaries can identify universal meanings of dream symbols. It is only through the associations relevant to a specific dreamer that we can make sense of a dream’s symbolism (Freud, 1938/1949). Finally, as the dream is actually presented to the conscious mind, the ego ensures that the material is acceptable by performing what Freud termed the secondary elaboration. As with any perception, the ego fills in gaps and connections, but also misunderstands the true nature of the dream. As a result the secondary elaboration can offer little more than a smooth façade for the dream. Also, the secondary elaboration may only be partial, or even absent (Freud, 1933/1965). All of these processes together form the manifest content of the dream, resulting in something that might be difficult to understand, but which is within the reach of a determined psychoanalyst.

    Discussion Question: Have you ever analyzed your own dreams? Were you able to discover any revelations after considering a dream in greater depth, even though it made no sense at first?

    The Therapeutic Process

    Initially, Freud began with a fundamental belief in the effectiveness of catharsis, the discharge of pent-up emotion that follows the recall and re-experiencing of traumatic memories (see Jarvis, 2004). If only a patient can recognize the unconscious association between an early traumatic event and their current symptoms, then the symptoms should be relieved. As Breuer and Freud noted in the introduction to their book:

    For we found, at first to our great surprise, that the individual hysterical symptoms disappeared immediately and did not recur if we succeeded in wakening the memory of the precipitating event with complete clarity, arousing with it the accompanying affect, and if the patient then depicted the event in the greatest possible detail and put words to the affect. Remembering without affect almost always fails to be effective… (pg. 10; Freud and Breuer, 1895/2004).

    One can see from this description, however, that the process of psychoanalysis is not easy. There must be a clear recognition of the initial traumatic event, in detail, with all of its original emotional impact, and the patient must then be willing to talk about the event in relation to their current problems.

    As we have already seen, the first obstacle is resistance, the patient’s reluctance to experience the anxiety associated with recovering repressed material. The more severe the symptoms, the more severe the resistance is likely to be. Even when a little trick is successful, such as pressing on the forehead to break the patient’s concentration and allow free association, in serious cases the self remembers its intentions (which are often unconscious motives) and resumes its resistance (Freud & Breuer, 1895/2004). Because of this challenge, Freud believed that the therapist must be patient. Resistance that has been constituted over a long period of time can only be resolved slowly, step by step. In addition to the intellectual role of the therapist, there is an important emotional role as well. In some cases, Freud found that only the personal influence of the doctor could successfully break down the patient’s defense mechanisms.

    A large part of the reason that psychoanalysis can be so difficult has to do with how the unconscious mind exists. Freud believed that memory of a traumatic event exists as a pathogenic nucleus within multiple layers of pathogenic psychical material of varying resistance. The outer layers may be easy to uncover, but as one progresses into the deeper layers, resistance grows steadily. Adding to the challenge, the associations between layers do not simply go deeper, they can travel at odd angles, in something of a zigzag fashion, or branch out in multiple ways (Freud & Breuer, 1895/2004). Because multiple associations may exist between a patient’s neurosis and the underlying traumatic event, it is critical to address all of the psychical material that comes to bear on the current condition of the patient. Even if the therapist rightly knows the basis for the patient’s problems:

    …there is no point at all in advancing directly to the nucleus of the pathogenic organization. Even if it were possible for us to guess this, the patient would not know what to do with the elucidation given to him and would not be altered by it psychically. (pg. 293; Freud & Breuer, 1895/2004)

    As suggested above, a different kind of obstacle arises when the relationship between the doctor and the patient has been damaged somehow. Freud considered this to be a likely occurrence in serious cases of analysis. Freud described three ways in which the doctor/patient relationship can suffer. The first case involves the patient feeling estranged, neglected, undervalued, insulted, or if they have heard negative things about the doctor. Freud considered this problem to be fairly easily handled through good communication, although he noted that good communication can be difficult with hysterical patients. The second situation involves patients who fear that they will become too dependent on the therapist and that they will lose their independence. This can lead to new resistances. As an example, Freud described patients who complained of headaches when he pressed on their forehead, but really they were just creating a new hysterical symptom to mask their aversion to the belief that they were being manipulated or controlled. The final problem that commonly disturbs the relationship between the therapist and the patient is known as transference (Freud & Breuer, 1895/2004). Transference occurs when the patient reacts as if the therapist were an important figure from the patient’s childhood or past, and transfers onto the therapist feelings and reactions appropriate to that person from the past. Although transference can interfere with the therapeutic process, it also offers advantages. The power conferred on the therapist by transference affords him an opportunity to re-educate the patient, correcting the mistakes of the parents, and it leads patients to reveal more about themselves than they might have if they had not developed such a connection to the therapist (Freud, 1938/1949).

    Following transference, it is also possible for countertransference to occur. Countertransference refers first to an unconscious influence of the patient on the therapist, after which the therapist directs their own emotional states back onto the patient. In Freud’s circle of analysts their own psychoanalysis was conducted in large part to eliminate the influence of this distorting effect. Today, there are some therapists who view countertransference as a useful means to gain a deeper perception about what is going on in their patient’s mind (see Jarvis, 2004).

    Is Psychoanalysis Effective?

    The effectiveness of psychoanalysis as a treatment for psychological disorders has been a source of ongoing debate. In 2006, a select task force, established by the presidents of five major psychoanalytic organizations, published the Psychodynamic Diagnostic Manual (PDM Task Force, 2006). Included within the PDM is a section on research, including meta-analytic studies on the effectiveness of psychoanalysis on patient populations in the United States (Westen et al., 2006), the United Kingdom (Fonagy, 2006), and Germany (Leichsenring, 2006). Each of these chapters emphasize the difficulty in empirically evaluating the effectiveness of psychotherapy, and even more so comparing the effectiveness of different psychotherapeutic approaches. Nonetheless, for a variety of psychological disorders, there is evidence supporting the efficacy of psychoanalytic treatments. Both Fonagy (2006) and Leichsenring (2006) identify another area of research that needs to be continued: there is not just one type of psychoanalysis. Thus, continued research on the efficacy of psychoanalytic treatments should address the relative efficacy of different styles of psychoanalytically based therapies.