What is psychoanalysis?

The Theoretical Basis of Psychoanalysis

Psychoanalysis is a method that is used to understand the workings of the human mind. Adherents to psychoanalysis believe that many forces operate to influence and shape the mind, including some that exist beneath the level of conscious awareness and control. Psychoanalysis permits scientists to observe and collect information about the mind, to develop and test scientific hypotheses about mental processes, and to use the scientific wisdom gained to diagnose and treat mental illnesses. Psychoanalytic theory helps psychiatrists and other mental health practitioners understand more about human emotions and psychological development. Though many psychoanalytic concepts were first developed only in the late nineteenth century, psychoanalysis has made significant and lasting contributions to modern psychiatry and continues to enhance its development.

The precepts of psychoanalysis have been subjected to much scientific scrutiny and criticism. As befits any scientific discipline, psychoanalytic theory has been revised periodically to account for new information, observations, and insights. Psychoanalytic theory also is seen as contributing to other scientific disciplines, such as neurology, the social sciences, and psychology. Psychoanalysis has also broadened understanding in the humanities, the arts, philosophy, ethics, and religion. Psychoanalysis clearly has had a profound and lasting impact upon a broad span of human interests and activities.

Psychoanalytic theory is largely a product of the efforts of
Sigmund Freud (1856–1939) to link the physical processes of the human brain with the psychological manifestations of the human mind. While Freud was frustrated in his ultimate goal of demonstrating clearly the relationship between the two, his work informs the same search today. Therefore, an understanding of early and evolving psychoanalytic theory remains important to psychiatry and psychotherapy.

To begin developing an understanding of the complexities of psychoanalysis, one needs to be familiar with basic information about psychoanalytic theory. The discussion that follows will touch on instinctual drives, the architecture of the mind, psychological development, mental defense mechanisms, and the psychoanalytic classification of mental illness.

Human behavior is driven from early infancy on by the operation of basic instincts. Freud believed that the primitive and evolving physical needs of humans stimulate instinctual drives. He said instincts possess four essential characteristics: source, impetus, aim, and object. Instincts arise from a particular bodily area, generate varying amounts of energy, aim for gratification, and are directed at particular objects, such as other people. Libido, one of these instincts, drives humans to seek pleasure and provides gratification during all the several stages of human development, beginning with the infant sucking at the mother’s breast. Later in his work, Freud expressed his belief that humans possess an aggressive instinct, which appears to be aimed at the destruction of the self and others. His formulation of dual and dueling instincts, as with much of his work, continues to evoke controversy in psychoanalytic circles.

Freud believed that the libido instinct is expressed early in life and continues to be expressed during several stages as a prelude to mature psychosexual development. Infants first experience the oral stage, which centers on feeding. Libido is gratified during the act of nursing, and success experienced at this stage helps the infant develop a sense of trust and self-reliance. Older infants proceed to the anal stage, centering on the retention and expulsion of feces and urine. Successful experience during the anal stage equips children with what they need to develop personal autonomy, independence, guiltless initiative, self-assurance, and willingness to cooperate. Children then move to the phallic stage, finding a new interest in genitalia. Freud’s theories about this stage are controversial, and many have been repudiated. He said that the penis holds the interest of both sexes, but girls form an early sense of inadequacy when they see that they do not have one (penis envy). Early sexual feelings are directed, according to Freud, toward the parent of the opposite sex (Oedipus complex). Parents regard these feelings as unacceptable and send signals to the children, who must repress their sexual urges. Boys act
out of fear of castration, while girls act out of fear of loss of parental love and of envy of the boy’s penis. Children who successfully negotiate this stage are said to have developed a firm basis for sexual identity, uninhibited curiosity, a sense of mastery, and the formation of conscience. Next comes the latency period, from ages five to thirteen, during which previous attainments are integrated and consolidated. Key elements of adaptive behavior develop during this stage. The teenage years are said to be spent in the genital stage, during which the child separates gradually from dependence on parents and begins to attach to new love objects and more mature interests. This stage culminates successfully in a sense of personal identity and acceptance.

Through Freud’s study of and work with hysteria, a condition in which emotional conflicts are transformed into bodily maladies, he became convinced that the human mind contains dynamic forces that often oppose one another. For example, a person who experiences significant trauma in early childhood, and the painful emotions that attend it, can mentally oppose or repress memories of the trauma and the traumatic emotions. The repressed memories and emotions remain embedded in the unconscious regions of the mind until they are revived and re-experienced when stimulated by a later event. Thus, the force of emotional material that was repressed but never forgotten can exceed the force used by the conscious mind to hold the memories at bay. The concepts of repression and the needful recognition of repressed material continue to be important principles guiding psychoanalysis.

Freud conceived of the human mind, or psyche, as having three parts: id, ego, and superego. The basic instincts and repressed Oedipal urges of human beings reside in the id. Freud saw the id as a totally undifferentiated mass of energy, constantly seeking gratification without the constraints of reality or morality. In contrast, he saw the ego as being well organized, governed by an accurate perception of the external environment, and honoring certain principles of socially acceptable behavior. The ego seeks to form gratifying relationships with other people. At the same time, the ego must defend itself against the primitive urges of the id. The superego is the last division of the mind to form, which it does through successful resolution of the Oedipus conflict. It forms what is called the conscience and imposes control through guilt. The superego often operates during dreams, Freud said, sending warnings when the ego fails to defend properly against id impulses. Most work of the id and the superego is carried out unconsciously, while much of the ego’s work operates at the conscious level.

After Freud had seen his theories confirmed in his clinical and personal experience, he felt comfortable in setting out his thoughts on psychopathology. Among the disorders that he identified were various types of neuroses, phobias, perversions, character disorders, personality disorders, psychoses, hypochondriasis, depressive states, and schizophrenia. He believed that mental illness is caused mainly by intrapsychic conflicts that are poorly managed by the mind or by abnormal mental processes and structures.

Indications and Procedures

In relation to medical science and, more specifically, to psychiatry, psychoanalysis is used to diagnose and treat emotional illness.

In diagnosis, psychoanalysts have purposes that differ considerably from those of general psychiatry. The analyst uses diagnosis to determine the patient’s potential for analysis, the usefulness of analysis in treating the particular emotional problem experienced by the patient, the patient’s level of incapacity, the likelihood that the patient will improve, and the likelihood that the analyst will be able to understand and help the patient. Other mental health specialists typically compare the signs and symptoms demonstrated or described by the patient to those cataloged in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed., 2013) and assign a diagnosis that best fits the patient. The psychoanalytic approach to diagnosis, conversely, is based on what the analyst can learn about the patient’s inner experiences, especially unconscious conflicts and fantasies.

Psychoanalysis is considered to be the treatment of choice for younger adults suffering from chronic emotional illness not helped by less intensive therapies. People who suffer from hysteria, obsessive-compulsive neuroses, sexual perversions, and certain personality disorders are seen as the best candidates for psychoanalysis. To be considered for psychoanalysis, patients must demonstrate an ability to develop a reasonably good relationship with an analyst and must be willing and able to withstand a long, intensive course of treatment. Psychoanalysis is also expensive, and patients must be able to pay for treatment. Some, but not all, third-party payers will bear part of the cost of psychoanalysis; unfortunately, third-party review of the case compromises analyst-patient confidentiality. Patients who are psychotic or who are alcoholics or drug addicts are considered poor candidates for psychoanalysis. Older adults may have personalities too rigid to tolerate analysis, and others have an illness too minor to justify such treatment. Patients who are chronically and deeply depressed may be unsuitable candidates for analysis, as are those who have failed to establish appropriate relationships with both parents. Patients must be deemed able not only to enter analysis but also to tolerate termination of therapy. Patients who need urgent intervention to preserve health and life are not good candidates for analysis; neither are those who have little opportunity to make changes in their lives. Because many factors enter into consideration, analysts give some patients a trial period of analysis before accepting them for treatment.

When a patient enters into psychoanalysis, the patient and analyst must resolve certain practical issues, such as setting up appointment times, payment schedules, and other policy matters. The patient must be willing to spend an hour a day, four or five days a week, for as long as five years to complete analysis.

The analyst and patient must be able to form a therapeutic relationship secure enough to withstand the test of time and the stress of treatment. Early on, the patient and analyst must endure as the patient anxiously defends the ego and resists plunging into deeper emotional material. Eventually, so-called transference
neurosis emerges. Patients re-experience and often project onto the analyst infantile desires and conflicts. The process of returning to more primitive emotional states is called regression, and analysts must be skillful in helping the patient to avoid its inherent dangers.

Free association is used to deepen the regression. The analyst instructs the patient to talk freely about issues of current concern and to continue talking about whatever associations come into the patient’s awareness, making no effort to censor or restrain the monologue. Despite a patient’s apparent willingness to follow the analyst’s direction, the patient’s resistance to uncovering certain material begins to be demonstrated with silences, pauses, stammers, corrections, slips of the tongue, and so on. The analyst remains alert to these signals of resistance, as the shape of the resistance shows the nature of the neurosis. The analyst gives interpretations of the resistance and related unconscious material; for progress to be made, the interpretation must be accurate, and the patient must accept and make use of it. The patient must work through painful emotional conflicts and find ways to resolve them more satisfactorily. “Working through” consumes much of the time spent in analysis.

The analyst often employs several psychological maneuvers to help patients during analysis. The analyst might offer suggestions, in an effort to induce a mental state that opposes the patient’s experiences, expectations, or concept of reality. For example, the analyst may assure the patient that working through repressed emotions will enable the patient to enjoy a more productive life. The analyst may manipulate the patient to facilitate recovery of or to neutralize early unconscious material. The analyst can help the patient by clarifying material that the patient may know only in a semiconscious, disorganized way. The term “countertransference” describes the variety of responses felt by the analyst toward the patient; the analyst must resolve such feelings satisfactorily in order to continue the analytic process.

Dreams are said to be the “royal road to the unconscious,” and the analyst will often encourage the patient to recall dreams experienced the preceding night. Dreams not only process waking experiences but often offer clues as to unconscious reactions, wishes, and conflicts as well. The analyst offers interpretations of the dreams in order to bring unconscious material and patterns to the conscious awareness of the patient.

The couch on which the patient reclines during sessions is a trademark of psychoanalysis; it is used rarely in any other form of psychotherapy. The analyst typically is positioned outside the visual range of the patient. This arrangement is considered to be essential in encouraging regression and projection.

As the patient and analyst struggle together to help the patient bring repressed material into awareness, the patient may achieve greater self-understanding and increased ability to find more satisfactory resolutions to emotional conflicts.

The analyst begins to prepare the patient for termination as the active phase of the analysis comes to a close. Patients must be weaned well from dependence on the analyst and the analytic situation. While the patient may have relived and worked through many primitive wishes and conflicts, the continuing work of resolving conflicts as they arise rests primarily with the patient’s ability to work through them independently.

The outcome of psychoanalysis can be difficult to evaluate, but success has been defined as having helped a patient improve adjustment to life, realize a certain amount of contentment, give happiness to others, deal more confidently with inevitable stresses, and maintain mutually satisfying relationships with others. In addition, the patient should experience a reduction in neurotic suffering and inhibitions, have fewer dependency needs, have increased potential for success in all significant areas of life, and function at a more mature level.

Perspective and Prospects

Psychoanalysis was born in the wake of evidence that hysteria can be caused by repressed memories or unconscious wishes. People who suffer from hysteria, now known as conversion disorder (functional neurological symptom disorder), develop physical symptoms such as paralysis or blindness in an otherwise healthy body. Sigmund Freud was influenced by the work of French neurologist Jean-Martin Charcot (1825–1893) and fellow Viennese physician Josef Breuer (1842–1925), both of whom were trying to find effective treatments for hysteria. Charcot relied on the use of hypnosis, while Breuer allowed patients to empty their minds, in an early version of free association. In 1895, Breuer and Freud published accounts of their theories and successful cures of patients suffering from hysteria. Freud also was influenced by the work of others on the hierarchy of the nervous system, philosophical concepts of the unconscious mind, posthypnotic suggestion, and the organization of the brain. He was a prolific author and teacher who fostered the careers of several followers.

Many of those who learned from and were influenced by Freud later developed their own variations or new areas of emphasis within Freudian psychoanalysis. Closer study of the role of the ego in emotional disorders led to the development of ego psychology, which enhanced the understanding of the defense, coping, and adaptive mechanisms of the ego. Others chose to emphasize the role of parents and other significant early childhood caregivers in the subsequent development of emotional health and illness. Still others developed what is known as self-psychology, a variant which emphasizes the importance of a person’s cohesive sense of self and emotional well-being; the sense of self is either fostered or hindered by interpersonal relationships formed throughout life. Other variants that draw on the psychoanalytical principle include psychodynamic, insight-oriented, relationship, and supportive psychotherapies. Marital, group, and family therapy also depend heavily on an understanding and application of psychoanalytical theory. Generally speaking, most psychotherapeutic interventions used today are grounded in the psychoanalytic precepts developed by Freud and refined by students of his work.

Classical psychoanalysis is still practiced in the United States, but its use is limited by the relatively few properly trained analysts, the time and expense involved in the treatment process, the lack of widely accepted proof of its superiority as a treatment method, and the demand for brief intervention by patients of psychotherapy and those who pay for it. Modern practitioners of psychoanalysis are concerned by several trends: the ascendence of biological approaches to understanding and treating mental illness, the unwillingness of insurers to pay for psychoanalysis, the growing number of nonphysician analysts, the growing skepticism about its effectiveness, and the establishment of a universal system of psychiatric diagnosis that largely ignores the psychoanalytic perspective.

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