Psychoanalysis

Psychoanalysis is a family of psychological theories and methods based on the pioneering work of Sigmund Freud. As a technique of psychotherapy psychoanalysis seeks to elucidate connections among unconscious components of patients' mental processes. The analyst's goal is to help liberate the analysand from unexamined or unconscious barriers of transference and resistance - that is, past patterns of relatedness that are no longer serviceable or that inhibit freedom.

Controversy rages both within and without the psychoanalytic community over whether psychoanalysis is a science, a pseudoscience, or something else altogether.

History

Psychoanalysis was first devised in Vienna in the 1890s by Sigmund Freud, a neurologist interested in finding an effective treatment for patients with neurotic or hysterical symptoms. As a result of talking with these patients, Freud came to believe that their problems stemmed from culturally unacceptable, thus repressed and unconscious, desires and fantasies of a sexual nature. As his theory developed, Freud developed and cast aside a myriad of different frameworks to model and explain the phenomena he encountered in treating his patients.

Prominent current schools of psychoanalysis include:

self psychology, which emphasizes the development of a stable sense of self through mutually empathic contacts with other humans;
Lacanian psychoanalysis, which integrates psychoanalysis with semiotics and Hegelian philosophy;
analytical psychology, which has a more spiritual approach;
object relations theory, which stresses the dynamics of one's relationships with internal, fantasized, others;
interpersonal psychoanalysis, which accents the nuances of interpersonal interactions; and
relational psychoanalysis, which combines interpersonal psychoanalysis with object-relations theory.

Although these schools have dramatically different theories, most of them continue to stress the strong influence of self-deception and the influence a person's past has on their current mental life.

Today psychoanalytic ideas are imbedded in the culture, especially in childcare, education, literary criticism, and in psychiatry, particularly medical and non-medical psychotherapy. Though there is a mainstream of evolved analytic ideas, there are groups who more specifically follow the precepts of one or more of the later theoreticians.

Technique

The basic method of psychoanalysis is the transference and resistance analysis of free association. The patient, in a relaxed posture, is directed to say whatever comes to mind. Dreams, hopes, wishes, and fantasies are of interest, as are recollections of early family life. Generally the analyst simply listens, making comments only when, in his or her professional judgment, an opportunity for insight on the part of the patient arises. In listening, the analyst attempts to maintain an attitude of empathic neutrality, a nonjudgmental stance designed to create a safe environment. The analyst asks that the analysand speak with utter honesty about whatever comes to awareness while interpreting the patterns and inhibitions that appear in the patient's speech and other behavior.

Many clinicians hold that psychoanalysis counter-indicated in cases of serious psychological disruption, such as psychosis, suicidal depression, or severe untreated alcoholism. Such patients may be labeled "un-analyzable". More typical applications include treatment of clinical depression and personality disorders.

Some more recent forms of psychoanalysis seek, among other things, to help patients gain self-esteem through greater trust of the self, overcome the fear of death and its effects on current behavior, and maintain several relationships that appear to be incompatible.

Although single-client sessions remain the norm, psychoanalysis has been adapted as a form of group therapy by Harry Stack Sullivan and others.

Efficacy

Currently, most psychoanalysts claim that analysis is most useful as a method in cases of neurosis and with character or personality problems. Psychoanalysis is believed to be most useful in dealing with ingrained problems of intimacy and relationship and for those problems in which established patterns of life are problematic. As a therapeutic treatment, psychoanalysis generally takes three to five meetings a week and requires the amount of time for natural or normal maturational change (three to seven years).

Analysis of previous randomised controlled trials have suggested that psychoanalytic treatment is more effective than the absence of treatment in specific psychiatric disorders. ^*. Empirical research on the efficacy of psychoanalysis and psychoanalytic psychotherapy has also become prominent among psychoanalytic researchers.

Research on psychodynamic treatment of some populations shows mixed results. Research by analysts such as Bertram Karon and colleagues at Michigan State University had suggested that when trained properly, psychodynamic therapists can be effective with schizophrenic patients. More recent research casts doubt on these claims. The Schizophrenia Patient Outcomes Research Team (PORT)report argues in its Recommendaton 22 against the use of psychodynamic therapy in cases of schizophrenia, noting that more trials are necessary to verify its effectiveness. However, it has been noted that the PORT recommendation is based on the opinions of clinicians rather than on empirical data, and empirical data exists that contradicts this recommendation.link to abstract A review of current medical literature in The Cochrane Library, (the updated abstract of which is available online) reached the conclusion that no data exist supporting the view that psychodynamic psychotherapy is effective in treating schizophrenia. Further, data also suggest that psychoanalysis is not effective (and possibly even detrimental) in the treatment of sex offenders.

Cost and length

Although psychoanalytic treatment used to be expensive, cost today ranges from as low as ten dollars a session (with an analytic candidate in training at an institute) to over 250 dollars a session with a senior training analyst.

Length of treatment varies. Some psychodynamic approaches, such as Brief Relational Therapy (BRT), Brief Psychodynamic Therapy (BPT), and Time-Limited Dynamic Therapy (TLDP) limit treatment to 20-30 sessions. Full-fledged psychoanalysis, however, generally lasts longer- with an average of 5.7 years, according to a recent survey. Which treatment length is optimal depends on the individual's needs. Managed care has placed increased pressure on psychotherapy in general to restrict time devoted to patients.

In addition to the greater length and frequency of treatment, one factor driving the cost of psychoanalysis in the United States has been the restrictive admissions policies of most training institutes, which has limited the supply of professionals available to meet demand. In Europe and Latin America, although psychoanalysis is sometimes perceived as an indulgence of the bourgeoisie, it is still more generally available and affordable than in the US.

Training

Throughout the history of psychoanalysis, most psychoanalytic organizations have existed outside of the university setting, with a few notable exceptions.

Psychoanalytic training usually occurs at a psychoanalytic institute and may last approximately 4-10 years. Training includes coursework, supervised psychoanalytic treatment of patients, and personal psychoanalysis lasting 4 or more years.

An ongoing debate in professional psychoanalysis concerns the prior qualifications candidates must have to enter analytic training. Freud believed that applicants from the humanities and many nonmedical disciplines are as well prepared as physicians for psychoanalytic training.

The American Psychoanalytic Association, however, limited access to training to medical doctors until quite recently. Later, after extensive debates and legal battles, psychoanalytic training in most institutes was opened to nonmedical mental health professionals, such as psychologists and clinical social workers. Currently, access to training by applicants from nonclinical disciplines, such as literary studies and philosophy, is limited to a handful of institutes in the United States. By contrast, many or most institutes in Europe and Latin America admit candidates without formal clinical training.

Although the popularity of psychoanalysis was in decline during the 1980's and early 1990's, prominent psychoanalytic institutes have experienced an increase in the number of applicants in recent years. link to article

Theory

The theories distinctive of psychoanalysis generally include the following hypotheses:

Human development is best understood in terms of changing objects of sexual desire.

The psychic apparatus habitually represses wishes, usually of a sexual or aggressive nature, whereby they become preserved in one or more unconscious systems of ideas.

Unconscious conflicts over repressed wishes have a tendency to manifest themselves in dreams, parapraxes ("Freudian slips"), and symptoms.

Unconscious conflicts are the source of neuroses.

Neuroses can be treated through bringing the unconscious wishes and repressed memories to consciousness in psychoanalytic treatment.

The unconscious and psychic structures

The unconscious refers to that part of mental functioning of which subjects make themselves unaware. The psychoanalytic unconscious is similar to but not precisely the same as the popular notion of the subconscious. For psychoanalysis, the unconscious does not include all of what is simply not conscious - it does not include e.g. motor skills - but rather, only what is actively repressed from conscious thought.

For Freud, the unconscious was a depository for socially unacceptable ideas, wishes or desires, traumatic memories, and painful emotions put out of mind by the mechanism of psychological repression. However, the contents did not necessarily have to be solely negative. In the psychoanalytic view, the unconscious is a force that can only be recognized by its effects - it expresses itself in the symptom.

The ego, super-ego, and id are the divisions of the psyche according to Freud's later "structural theory". The id contains "primitive desires" (hunger, rage, and sex), the super-ego contains internalized norms, morality and taboos, and the ego mediates between the two and may include or give rise to the sense of self.

Roots of neurosis

In his earliest writings on the subject, Freud theorized that all neuroses were rooted in childhood sexual abuse (the so-called seduction theory). Later, Freud came to abandon or de-emphasize this hypothesis, emphasizing instead the importance of unconscious fantasy as the cause of neurosis, particularly fantasy structured according the the Oedipus complex.

The Oedipus complex is a concept developed by Sigmund Freud to explain the origin of certain neuroses in childhood. It is defined as a male child's unconscious desire for the exclusive love of his mother. This desire includes jealousy towards the father and the unconscious wish for that parent's death. The idea is based on the Greek myth of Oedipus, who unwittingly kills his father Laius and marries his mother Jocasta.

Freud revisited the Oedipal territory in the final essay of Totem and Taboo. There, he combined one of Charles Darwin's more speculative theories about the arrangements of early human societies (a single alpha-male surrounded by a harem of females, similar to the arrangement of gorilla groupings) with the theory of the sacrifice ritual taken from William Robertson Smith located the origins of totemism in a singular event, whereby a band of prehistoric brothers expelled from the alpha-male group returned to kill their father, whom they both feared and respected. In this respect, Freud located the beginnings of the Oedipus complex at the origins of human society, and postulated that all religion was in effect an extended and collective form of guilt and ambivalence to cope with the killing of the father figure (which he saw as the true original sin).

The life and death instincts

Freud believed that humans were driven by two conflicting central desires: the life drive (Eros) (incorporating the sex drive) and the death drive (Thanatos). Freud's description of Eros/Libido included all creative, life-producing drives. The Death Drive (or death instinct) represented an urge inherent in all living things to return to a state of calm, or, ultimately, of non-existence. The presence of the Death Drive was only recognized in his later years, and the contrast between the two represents a revolution in his manner of thinking.

Post-Freudian schools

Object relations theory is the idea that the ego-self exists only in relation to other objects, which may be external or internal. Internal objects are internalized versions of external objects, primarily formed from early interactions with the parents. According to object-relations theory there are three fundamental "affects" that can exist between the self and the other - attachment, frustration, and rejection. These affects are alleged to be universal emotional states that are major building blocks of the personality. Object relations theory was pioneered in the 1940's and 50's by British psychologists Ronald Fairbairn, D.W. Winnicott, Harry Guntrip, and others.
Interpersonal psychoanalysis is based on the theories of Harry Stack Sullivan, an American psychiatrist who believed that the details of patient's interpersonal interactions with others provided insight into the causes and cures of mental disorder. Sullivan argued that patients keep many aspects of interpersonal relationships out of their awareness by selective inattention. He felt that it to be important for psychotherapists to conduct a detailed inquiry into patient's interactions with others so that patients would become optimally aware of their interpersonal patterns.

Criticisms

Psychoanalysis has been criticized on a variety of grounds by Karl Popper, Adolf Grünbaum, Mario Bunge, Hans Eysenck, Ludwig Wittgenstein, Peter Medawar, Ernest Gellner, Frank Cioffi, Frederick Crews, Arthur Janov, L. Ron Hubbard and others. Popper argues that it is not scientific because it is not falsifiable. Grünbaum argues that it is falsifiable, and in fact turns out to be false. Janov claims that psychoanalysis intellectualizes the feeling process which only strengthens defenses. The other schools of psychology have produced alternative methods of psychotherapy, including behavior therapy, cognitive therapy, primal therapy and person centered psychotherapy. Exchanges between critics and defenders of psychoanalysis have often been so heated that they have come to be characterized as the Freud Wars.

An important consequence of the wide variety of psychoanalytic theories is that psychoanalysis is difficult to criticize as a whole. Many critics have attempted to offer criticisms of psychoanalysis that were in fact only criticisms of specific ideas present only in one or more theories, rather than in all of psychoanalysis. For example, it is common for critics of psychoanalysis to focus on Freud's ideas, even though only a fraction of contemporary analysts still hold to Freud's major theses. As the psychoanalytic researcher Drew Westen puts it, "Critics have typically focused on a version of psychoanalytic theory—circa 1920 at best—that few contemporary analysts find compelling...In so doing, however, they have set the terms of the public debate and have led many analysts, I believe mistakenly, down an indefensible path of trying to defend a 75 to 100-year-old version of a theory and therapy that has changed substantially since Freud laid its foundations at the turn of the century." link to Westen article

Scientific Validity

An early and important criticism of psychoanalysis was that its theories were based on little quantitative and experimental research, and instead relied almost exclusively on the clinical case study method. In comparison, brief psychotherapy approaches such as behavior therapy and cognitive therapy have shown much more concern for empirical validation (see, e.g., Morley and al. 1999). Some even accused Freud of fabrication, including the famous and miraculous cure of Anna O. (Borch-Jacobsen, 1996).

An increasing amount of psychoanalytic research from academic psychologists and psychiatrists who have worked to quantify and measure psychoanalytic concepts has begun to address this criticism. However, a survey of scientific research showed that while personality traits corresponding to Freud's oral, anal, Oedipal, and genital phases can be observed, they cannot be observed as stages in the development of children, nor it be confirmed that such traits in adults result from childhood experiences (Fisher & Greenberg, 1977, p399).

E. Fuller Torrey, considered by some a leading American psychiatrist, writing in Witchhdoctors and Psychiatrists (1986) stated that psychoanalytic theories have no more scientific basis than the theories of traditional native healers, "witchdoctors" or modern "cult" alternatives such as est. In fact, an increasing number of scientists regard psychoanalysis as a pseudoscience (Cioffi, F. 1998).

Among philosophers, Karl Popper argued that Freud's theory of the unconscious was not falsifiable, and therefore not scientific. Popper objected not so much to the idea that things happened in our minds that we are unconscious of; he objected to investigations of mind that were not falsifiable: if one could connect every imaginable experimental outcome with Freud's theory of the unconscious mind, then no experiment could refute the theory.

Some defenders of psychoanalysis suggest that its logics and formulations are more akin to those found in the humanities than those proper to the physical and biological sciences, though Freud himself tried to base his clinical formulations on a hypothetical neurophysiology of energy transformations. For example, the philosopher Paul Ricoeur argued that psychoanalysis can be considered a type of textual interpretation or hermeneutics. Like cultural critics and literary scholars, Ricoeur contended, psychoanalysts spend their time interpreting the nuances of language- the language of their patients. Ricoeur claimed that psychoanalysis emphasizes the polyvocal or many-voiced qualities of language, focusing on utterances that mean more than one thing. Ricoeur classified psychoanalysis as a hermeneutics of suspicion. By this he meant that psychoanalysis searches for deception in language, and thereby destabilizes our usual reliance on clear, obvious meanings.

Controversy over Efficacy

Psychoanalysts, for most of their history, have relied on the clinical case report as the chief method of evaluating the efficacy of treatment. In comparison, brief psychotherapy approaches such as behavior therapy and cognitive therapy have shown much more concern for empirical validation from broad-based studies modeled after randomized pharmaceutical trials. (see, e.g., Morley and al. 1999).

At least in the United States, psychoanalysis has usually been perceived as a form of insight-based therapy, with the goal of bringing unconscious thoughts or memories into consciousness. Some studies, however, throw doubt on whether insight is a necessary or sufficient means for improving a person's behavior or increasing their level of functioning (Fisher & Greenberg, 1977, pp411-412).

There is even a great controversy among psychologists as to whether repressed memories actually exist. The whole recovered memory movement, which has flourished in the United States in the last decade, is now highly criticized by the advocates of the false memory syndrome (Loftus & Ketcham, 1994).

Theoretical Criticism

Psychoanalysts have often complained about the significant lack of theoretical agreement among analysts of different schools. Many authors have attempted to integrate the various theories, with limited success.

The philosopher Jacques Derrida used psychoanalytic theory to question what he called the metaphysics of presence, a body of philosophical theory which assumes that the meaning of utterances can be pinned down and made fully evident.

Psychoanalysis, or at least the dominant version of it, has been denounced as patriarchal or phallocentric by proponents of feminist theory.

Influential practitioners and theorists

A few of the most influential psychoanalysts are/were Karen Horney, Jacob Arlow, John Benjamin, Wilfred Bion, Charles Brenner, Erik Erikson, Ronald Fairbairn, Sandor Ferenczi, Sigmund Freud, Merton Gill, Andre Green, Heinz Hartmann, Carl Jung, Otto Kernberg, Melanie Klein, Heinz Kohut, Luce Irigaray, Julia Kristeva, Jacques Lacan, Hans Loewald, Margaret Mahler, Donald Meltzer, Stephen A. Mitchell, David Rapaport, Roy Schafer, Daniel N. Stern, Neville Symington, Donald Winnicott, Theodor Reik, Harry Stack Sullivan, and Slavoj Zizek.

References

Brenner, C. (1954). An elementary textbook of psychoanalysis.
Corey, G. (2001). Theory and practice of counseling and psychotherapy. (6th ed.). Belmont, CA: Brooks/Cole Thompson Learning
Seymour Fisher,, The Scientific Credibility of Freud's Theories and Therapy, Columbia University Press (October, 1985), trade paperback, ISBN 023106215X
Firestone, R.W. (2002). "The death of psychoanalysis and depth therapy." version. Psychotherapy: Theory, Research, Practice, and Training, 39(3), 223-232.
Kramer, Peter D., Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self ISBN 0670841838.
Luhrmann, T.M., Of Two Minds: The Growing Disorder in American Psychiatry ISBN 0679421912.
Thomson, C.L, Rudolph L.B., & Henderson, D. (2004). Counseling children. (6th ed.). Belmont, CA: Brooks/Cole Thompson.
Psychoanalytic Theory: An Introduction, by Anthony Elliott, an introduction that explains psychoanalytic theory with interpretations of major theorists ^*
The Psychoanalytic Movement: The Cunning of Unreason, by Ernest Gellner. A critical view of Freudian theory. ISBN 0810113708
Mitchell, S. & Black, M. (1995). Freud and Beyond: A History of Modern Psychoanalytic Thought
Final Analysis The Making and Unmaking of a Psychoanalyst, Written by Jeffrey Moussaieff Masson, Publisher's review

Critiques of psychoanalysis

Borch-Jacobsen, M (1996). Remembering Anna O: A century of mystification. London, Routledge. ISBN 0415917778
Cioffi, F. (1998). Freud and the Question of Pseudoscience. Open Court Publishing Company. ISBN 081269385X
Erwin, Edward, A Final Accounting: Philosophical and Empirical Issues in Freudian Psychology ISBN 0262050501
Fisher S., Greenberg RP. (1977), The Scientific Credibility of Freud’s Theories and Therapy. New York: Basic Books, 1977.
Fisher S, Greenberg RP. (1996), Freud Scientifically Reappraised: Testing the Theories and Therapy. New York: John Wiley, 1996.
Gellner, Ernest, The Psychoanalytic Movement: The Cunning of Unreason. A critical view of Freudian theory. ISBN 0810113708
Grünbaum, Adolf (1979), Is Freudian Psychoanalytic Theory Pseudo-Scientific by Karl Popper's Criterion of Demarcation?, "American Philosophical Quarterly", 16, Ap 79, s.131-141.
Grünbaum, Adolf (1985) The Foundations of Psychoanalysis: A Philosophical Critique ISBN 0520050177
Janov, Arthur, "Grand Delusions." Chapter 8: Freud's theory as therapy: The talking cure that doesn't heal. ^*
Loftus, EF & Ketcham, K. (1994) The Myth of Repressed Memory. NY: St. Martin's Press.
Macmillan, Malcolm, and Frederick Crews, Freud Evaluated: The Completed Arc ISBN 0262631717
Morley S, Eccleston C, Williams A. (1999) Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999 Mar;80(1-2):1-13.
Webster R. (1995). "Why Freud was wrong ?", Basic Books, Harper Collins, NY NY. ISBN 0465091288
//skepdic.com/psychoan.html Skeptic's dictionary entry on psychoanalysis
//skepdic.com/repressedmemory.html Skeptic's dictionary entry on repressed memory

External links

The American Psychoanalytic Association

Online papers about psychoanalytic theory

Online papers and links about psychoanalytic research

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