Freudian psychoanalysis refers to a specific type of treatment in which the "analysand" (analytic patient) verbalizes thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the unconscious conflicts causing the patient's symptoms and character problems, and interprets them for the patient to create insight for resolution of the problems.
The specifics of the analyst's interventions typically include confronting and clarifying the patient's pathological defenses, wishes and guilt. Through the analysis of conflicts, including those contributing to resistance and those involving transference onto the analyst of distorted reactions, psychoanalytic treatment can clarify how patients unconsciously are their own worst enemies: how unconscious, symbolic reactions that have been stimulated by experience are causing symptoms.
Freud's first theory to explain hysterical symptoms was the so-called "seduction theory". Since his patients under treatment with this new method "remembered" incidents of having been sexually seduced in childhood, Freud believed that they had actually been abused only to later repress those memories. This led to his publication with Dr. Breuer in 1893 of case reports of the treatment of hysteria. This first theory became untenable as an explanation of all incidents of hysteria. As a result of his work with his patients, Freud learned that the majority complained of sexual problems, especially coitus interruptus as birth control. He suspected their problems stemmed from cultural restrictions on sexual expression and that their sexual wishes and fantasies had been repressed. Between this discovery of the unexpressed sexual desires and the relief of the symptoms by abreaction, Freud began to theorize that the unconscious mind had determining effects on hysterical symptoms.
His first comprehensive attempt at an explanatory theory was the then unpublished Project for a Scientific Psychology in 1895. In this work Freud attempted to develop a neurophysiologic theory based on transfer of energy by the neurons in the brain in order to explain unconscious mechanisms. He abandoned the project when he came to realize that there was a complicated psychological process involved over and above neuronal activity. By 1900, Freud had discovered that dreams had symbolic significance, and generally were specific to the dreamer. Freud formulated his second psychological theory – that of there being an unconscious "primary process" consisting of symbolic and condensed thoughts, and a "secondary process" of logical, conscious thoughts. This theory was published in his 1900 opus magnum, The Interpretation of Dreams. Chapter VII was a re-working of the earlier "Project" and Freud outlined his "Topographic Theory". In this theory, which was mostly later supplanted by the Structural Theory, unacceptable sexual wishes were repressed into the "System Unconscious", unconscious due to society's condemnation of premarital sexual activity, and this repression created anxiety. Freud also discovered what most of us take for granted today: that dreams were symbolic and specific to the dreamer. Often, dreams give clues to unconscious conflicts, and for this reason, Freud referred to dreams as the "royal road to the Unconscious."
In On Narcissism (1915) Freud turned his attention to the subject of narcissism. Still utilizing an energic system, Freud conceptualized the question of energy directed at the self versus energy directed at others, called cathexis. By 1917, In "Mourning and Melancholia",he suggested that certain depressions were caused by turning guilt-ridden anger on the self. In 1919 in "A Child is Being Beaten" he began to address the problems of self-destructive behavior (moral masochism) and frank sexual masochism. Based on his experience with depressed and self-destructive patients, and pondering the carnage of WW I, Freud became dissatisfied with considering only oral and sexual motivations for behavior. By 1920, Freud addressed the power of identification (with the leader and with other members) in groups as a motivation for behavior (Group Psychology and Analysis of the Ego). In that same year (1920) Freud suggested his "dual drive" theory of sexuality and aggression in, Beyond the Pleasure Principle, to try to begin to explain human destructiveness.
In 1923, he presented his new "structural theory" of an id, ego, and superego in a book entitled, The Ego and the Id. Therein, he revised the whole theory of mental functioning, now considering that repression was only one of many defense mechanisms, and that it occurred to reduce anxiety. Note the 180 degree shift - earlier he had thought that repression caused anxiety. Moreover, in 1926, in Inhibitions, Symptoms and Anxiety, Freud laid out how intrapsychic conflict among drive and superego (wishes and guilt) caused anxiety, and how that anxiety could lead to an inhibition of mental functions, such as intellect and speech. By 1936, the "Principle of Multiple Function" was clarified by Robert Waelder. He widened the formulation that psychological symptoms were caused by and relieved conflict simultaneously. Moreover, symptoms (such as phobias and compulsions) each represented elements of some drive wish (sexual and/or aggressive), superego (guilt), anxiety, reality, and defenses. Also in 1936, Anna Freud, Sigmund's famous daughter, published her seminal book, The Ego and the Mechanisms of Defense, outlining numerous ways the mind could shut upsetting things out of consciousness.
In the 2000s there are approximately 35 training institutes for psychoanalysis in the United States accredited by the American Psychoanalytic Association which is a component organization of the International Psychoanalytical Association, and there are over 3,000 graduated psychoanalysts practicing in the United States. The International Psychoanalytical Association accredits psychoanalytic training centers throughout the rest of the world, including countries such as Serbia, France, Germany, Austria, Italy, Switzerland, and many others, as well as about six institutes directly in the U.S. Freud published a paper entitled The History of the Psychoanalytic Movement in 1914, German original first published in the Jahrbuch der Psychoanalyse, 4.
Topographic theory was first described by Freud in "the Interpretation of Dreams" (1900) The theory posits that the mental apparatus can be divided in to the systems Conscious, Pre-conscious and Unconsious. These systems are not anatomical structures of the brain but, rather, mental processes. Although Freud retained this theory throughout his life he largely replaced it with the Structural theory. The Topographic theory remains as one of the metapsychological points of view for describing how the mind functions in classical psychoanalytic theory.
Structural Theory breaks the mind up into the id, the ego, and the superego. Actually, in German, the word for id is "es," which means "it." The word ego was coined by Freud's translators; Freud used the term, "ich" meaning "I" in English. Freud called the superego the "Über-ich." The id was designated as the repository of sexual and aggressive wishes, which Freud called "drives." The ego was composed of those forces that opposed the drives – defensive operations. The superego was Freud's term for the conscience – values and ideals, shame and guilt. One problem Brenner (2006) later found with this theory (see above) was that Freud also suggested that forgotten thoughts ("the repressed") were also "located" in the id. However, Freud here realized that drives could be conscious or unconscious, and that consciousness vs. unconsciousness was a quality of any mental operation or any mental conflict. Forgetting things could be done on purpose, or not. People could be aware of guilt, or not aware.
Ego psychology was initially suggested by Freud in Inhibitions, Symptoms and Anxiety (1926). The theory was refined by Hartmann, Loewenstein, and Kris in a series of papers and books from 1939 through the late 1960s. Leo Bellak was a later contributor. This series of constructs, paralleling some of the later developments of cognitive theory, includes the notions of autonomous ego functions: mental functions not dependent, at least in origin, on intrapsychic conflict. Such functions include: sensory perception, motor control, symbolic thought, logical thought, speech, abstraction, integration (synthesis), orientation, concentration, judgment about danger, reality testing, adaptive ability, executive decision-making, hygiene, and self-preservation. Freud noted that inhibition is one method that the mind may utilize to interfere with any of these functions in order to avoid painful emotions. Hartmann (1950s) pointed out that there may be delays or deficits in such functions.
Frosch (1964) described differences in those people who demonstrated damage to their relationship to reality, but who seemed able to test it. Deficits in the capacity to organize thought are sometimes referred to as blocking or loose associations (Bleuler), and are characteristic of the schizophrenias. Deficits in abstraction ability and self-preservation also suggest psychosis in adults. Deficits in orientation and sensorium are often indicative of a medical illness affecting the brain (and therefore, autonomous ego functions). Deficits in certain ego functions are routinely found in severely sexually or physically abused children, where powerful affects generated throughout childhood seem to have eroded some functional development.
Ego strengths, later described by Kernberg (1975), include the capacities to control oral, sexual, and destructive impulses; to tolerate painful affects without falling apart; and to prevent the eruption into consciousness of bizarre symbolic fantasy. Synthetic functions, in contrast to autonomous functions, arise from the development of the ego and serve the purpose of managing conflictual processes. Defenses are an example of synthetic functions and serve the purpose of protecting the conscious mind from awareness of forbidden impulses and thoughts. One purpose of ego psychology has been to emphasize that there are mental functions that can be considered to be basic, and not the derivatives of wishes, affects, or defenses. However, it is important to note that autonomous ego functions can be secondarily affected because of unconsious conflict. For example, a patient may have an hysterical amnesia (memory being an autonomous function) because of intrapsychic conflict (wishing not to remember because it is too painful).
Taken together, the above theories present a group of Metapsychological Assumptions. Therefore, the inclusive group of the different classical theories provides a cross-sectional view of human mentation. There are six "points of view", five of which were described by Freud and a sixth added by Hartmann. Unconscious processes can therefore be evaluated from each of these six points of view. The "points of view are" are: 1. Topographic 2. Dynamic (the theory of conflict) 3. Economic (the theory of energy flow) 4. Structural 5. Genetic (propositions concerning origin and development of psychological funtions) and 6. Adaptational (psychological phenomena as it relates to the external world).
Conflict Theory is an update and revision of structural theory that does away with some of the more arcane features of structural theory (such as where repressed thoughts are stored). Conflict theory looks at how emotional symptoms and character traits are complex solutions to intrapsychic conflict. See Brenner (2006), Psychoanalysis: Mind and Meaning, New York: Psychoanalytic Quarterly Press. This revision of Freud's structural theory (Freud, 1923, 1926) dispenses with the concepts of a fixed id, ego and superego, and instead posits unconscious and conscious conflict among wishes (dependent, controlling, sexual, and aggressive), guilt and shame, emotions (especially anxiety and depressive affect), and defensive operations that shut off from consciousness some aspect of the others. Moreover, healthy functioning (adaptive) is also determined, to a great extent, by resolutions of conflict.
A major goal of modern conflict theorist analysts is to attempt to change the balance of conflict through making aspects of the less adaptive solutions (also called compromise formations) conscious so that they can be rethought, and more adaptive solutions found. Current theoreticians following Brenner's many suggestions (see especially Brenner's 1982 book, "The Mind in Conflict") include Sandor Abend, MD (Abend, Porder, & Willick, (1983), Borderline Patients: Clinical Perspectives), Jacob Arlow (Arlow and Brenner (1964), Psychoanalytic Concepts and the Structural Theory), and Jerome Blackman (2003), 101 Defenses: How the Mind Shields Itself). Conflict theory is one of the analytic theories taught in psychoanalytic institutes, throughout the United States, accredited by the American Psychoanalytic Association.
Object relations theory attempts to explain vicissitudes of human relationships through a study of how internal representations of self and of others are structured. The clinical problems that suggest object relations problems (usually developmental delays throughout life) include disturbances in an individual's capacity to feel warmth, empathy, trust, sense of security, identity stability, consistent emotional closeness, and stability in relationships with chosen other human beings. (It is not suggested that one should trust everyone, for example). Concepts regarding internal representations (also sometimes termed, "introjects," "self and object representations," or "internalizations of self and other") although often attributed to Melanie Klein, were actually first mentioned by Sigmund Freud in his early concepts of drive theory (1905, Three Essays on the Theory of Sexuality). Freud's 1917 paper "Mourning and Melancholia", for example, hypothesized that unresolved grief was caused by the survivor's internalized image of the deceased becoming fused with that of the survivor, and then the survivor shifting unacceptable anger toward the deceased onto the now complex self image.
Vamik Volkan, in "Linking Objects and Linking Phenomena," expanded on Freud's thoughts on this, describing the syndromes of "Established pathological mourning" vs. "reactive depression" based on similar dynamics. Melanie Klein's hypotheses regarding internalizations during the first year of life, leading to paranoid and depressive positions, were later challenged by Rene Spitz (e.g., The First Year of Life, 1965), who divided the first year of life into a coenesthetic phase of the first six months, and then a diacritic phase for the second six months. Margaret Mahler (Mahler, Fine, and Bergman (1975), "The Psychological Birth of the Human Infant") and her group, first in New York, then in Philadelphia, described distinct phases and subphases of child development leading to "separation-individuation" during the first three years of life, stressing the importance of constancy of parental figures, in the face of the child's destructive aggression, to the child's internalizations, stability of affect management, and ability to develop healthy autonomy.
Later developers of the theory of self and object constancy as it affects adult psychiatric problems such as psychosis and borderline states have been John Frosch, Otto Kernberg, and Salman Akhtar. Peter Blos described (1960, in a book called On Adolescence) how similar separation-individuation struggles occur during adolescence, of course with a different outcome from the first three years of life: the teen usually, eventually, leaves the parents' house (this varies with the culture). During adolescence, Erik Erikson (1950-1960s) described the "identity crisis," that involves identity-diffusion anxiety. In order for an adult to be able to experience "Warm-ETHICS" (warmth, empathy, trust, holding environment (Winnicott), identity, closeness, and stability) in relationships (see Blackman (2003), 101 Defenses: How the Mind Shields Itself), the teenager must resolve the problems with identity and redevelop self and object constancy.
Self psychology emphasizes the development of a stable sense of self through empathic contacts with other humans, and first of all with the maternal figure conceived as "selfobject" was developed originally by Heinz Kohut, and has been elucidated by the Ornsteins and Arnold Goldberg. Marian Tolpin explicated the need for "transmuting internalizations" (1971) during treatment, to correct what Kohut referred to as a disturbance in the "self-object" internalizations from parents.
Lacanian psychoanalysis integrates psychoanalysis with semiotics and Hegelian philosophy, is popular in France and Latin America. Lacanian psychoanalysis is a departure from the traditional British and American psychoanalysis, which is predominantly Ego psychology. Lacan frequently used the phrase "retourner à Freud" in his seminars and writings meaning "back to Freud" as he claimed that his theories were an extension of Freud's own, contrary to those of Anna Freud, the Ego Psychology, object relations and "self" theories. Lacan's first major contributions concern the "mirror stage", the Real, the Imaginary and the Symbolic, and the claim the "unconscious is structured as a language".
Interpersonal psychoanalysis accents the nuances of interpersonal interactions, was first introduced by Harry Stack Sullivan, MD, and developed further by Frieda Fromm-Reichmann. It is the primary theory, still taught, at the William Alanson White Center.
Relational psychoanalysis combines interpersonal psychoanalysis with object-relations theory and with Inter-subjective theory as critical for mental health, was introduced by Stephen Mitchell. Relational psychoanalysis emphasizes how the individual's personality is shaped by both real and imagined relationships with others, and how these relationship patterns are re-enacted in the interactions between analyst and patient. Fonagy and Target, in London, have propounded their view of the necessity of helping certain detached, isolated patients, develop the capacity for "mentalization" associated with thinking about relationships and themselves.
Intersubjective psychoanalysis, the term "intersubjectivity" introduced in psychoanalysis by George E. Atwood and Robert Stolorow (1984). The authors of the relational and intersubjective approaches: Heinz Kohut, Stephen A. Mitchell, Jessica Benjamin, Bernard Brandchaft, J. Fosshage, Donna M.Orange, Arnold Modell, Thomas Ogden, Owen Renik, Harold Searles, Colwyn Trewarthen, Edgar A. Levenson, J. R. Greenberg, Edward R. Ritvo, Beatrice Beebe, Frank M. Lachmann, Herbert Rosenfeld and Daniel Stern.
Modern psychoanalysis is a body of theoretical and clinical knowledge developed by Hyman Spotnitz and his colleagues, extended Freud's theories so as to make them applicable to the full spectrum of emotional disorders. Modern psychoanalytic interventions are primarily intended to provide an emotional-maturational communication to the patient, rather than to promote intellectual insight.
Although these theoretical "schools" differ, most of them continue to stress the strong influence of unconscious elements affecting people's mental lives. There has also been considerable work done on consolidating elements of conflicting theory (cf. the work of Theodore Dorpat, B. Killingmo, and S. Akhtar). As in all fields of medicine (for example, }, there are some persistent conflicts regarding specific causes of some syndromes, and disputes regarding the best treatment techniques. In the 2000s, psychoanalytic ideas are embedded in Western culture, especially in fields such as childcare, education, literary criticism, cultural studies, and in psychiatry, particularly medical and non-medical psychotherapy. Though there is a mainstream of evolved analytic ideas, there are groups who follow the precepts of one or more of the later theoreticians. Psychoanalytic ideas also plays role in some types of literary analysis such as Archetypal literary criticism.
In patients whose autonomous ego functions are more intact, but who still show problems with object relations, the diagnosis often falls into the category known as "borderline." Borderline patients also show deficits, often in controlling impulses, affects, or fantasies – but their ability to test reality remains more or less intact. Adults who do not experience guilt and shame, and who indulge in criminal behavior, are usually diagnosed as psychopaths, or, using DSM-IV-TR, antisocial personality disorder.
Panic, phobias, conversions, obsessions, compulsions and depressions (analysts call these "neurotic symptoms") are not usually caused by deficits in functions. Instead, they are caused by intrapsychic conflicts. The conflicts are generally among sexual and hostile-aggressive wishes, guilt and shame, and reality factors. The conflicts may be conscious or unconscious, but create anxiety, depressive affect, and anger. Finally, the various elements are managed by defensive operations – essentially shut-off brain mechanisms that make people unaware of that element of conflict. "Repression" is the term given to the mechanism that shuts thoughts out of consciousness. "Isolation of affect" is the term used for the mechanism that shuts sensations out of consciousness. Neurotic symptoms may occur with or without deficits in ego functions, object relations, and ego strengths. Therefore, it is not uncommon to encounter obsessive-compulsive schizophrenics, panic patients who also suffer with borderline personality disorder, etc.
Many psychoanalysts who work with children have studied the actual effects of child abuse, which include ego and object relations deficits and severe neurotic conflicts. Much research has been done on these types of trauma in childhood, and the adult sequelae of those. On the other hand, many adults with symptom neuroses and character pathology have no history of childhood sexual or physical abuse. In studying the childhood factors that start neurotic symptom development, Freud found a constellation of factors that, for literary reasons, he termed the Oedipus complex (based on the play by Sophocles, Oedipus Rex, where the protagonist unwittingly kills his father Laius and marries his mother Jocasta). The shorthand term, "oedipal," (later explicated by Joseph Sandler in "On the Concept Superego" (1960) and modified by Charles Brenner in "The Mind in Conflict" (1982)) refers to the powerful attachments that children make to their parents in the preschool years. These attachments involve fantasies of marriage to either (or both) parent, and, therefore, competitive fantasies toward either (or both) parents. Humberto Nagera (1975) has been particularly helpful in clarifying many of the complexities of the child through these years.
The terms "positive" and "negative" oedipal conflicts have been attached to the heterosexual and homosexual aspects, respectively. Both seem to occur in development of most children. Eventually, the developing child's concessions to reality (that they will neither marry one parent nor eliminate the other) lead to identifications with parental values. These identifications generally create a new set of mental operations regarding values and guilt, subsumed under the term "superego." Besides superego development, children "resolve" their preschool oedipal conflicts through channeling wishes into something their parents approve of ("sublimations") and the development, during the school-age years ("latency") of age-appropriate obsessive-compulsive defensive maneuvers (rules, repetitive games).
The more there are deficits of serious magnitude in any of the above mental operations (1-8), the more psychoanalysis as treatment is contraindicated, and the more medication and supportive approaches are indicated. In non-psychotic first-degree criminals, any treatment is often contraindicated. The problems treatable with analysis include: phobias, conversions, compulsions, obsessions, anxiety attacks, depressions, sexual dysfunctions, a wide variety of relationship problems (such as dating and marital strife), and a wide variety of character problems (for example, painful shyness, meanness, obnoxiousness, workaholism, hyperseductiveness, hyperemotionality, hyperfastidiousness). The fact that many of such patients also demonstrate deficits above makes diagnosis and treatment selection difficult.
Analytical organizations such as the International Psychoanalytical Association, the American Psychoanalytical Association, the European Federation for Psychoanalytic Psychotherapy, etc. have established procedures and models for the indication and practice of psychoanalytical therapy for trainees in analysis. The match between the analyst and the patient can be viewed as another contributing factor for the indication and contraindication for psychoanalytic treatment. The analyst decides whether the patient is suitable for psychoanalysis. This decision made by the analyst, besides made on the usual indications and pathology, is also based to a certain degree by the "fit" between analyst and patient. When analysts utilize concrete, semi-standardized procedures to evaluate patients' suitability for analytic treatment, their associations' "defined protocols," may include (semi-) structured interviews, personality tests, projective tests, and/or psychological questionnaires. An evaluation may include one or more other analysts' independent opinions and will include discussion of the patient's financial situation and insurances.
When the patient reclines on a couch with the analyst out of view, the patient tends to remember more, experience more resistance and transference, and be able to reorganize thoughts after the development of insight – through the interpretive work of the analyst. Although fantasy life can be understood through the examination of dreams, masturbation fantasies (cf. Marcus, I. and Francis, J. (1975), Masturbation from Infancy to Senescence) are also important. The analyst is interested in how the patient reacts to and avoids such fantasies (cf. Paul Gray (1994), The Ego and the Analysis of Defense). Various memories of early life are generally distorted – Freud called them "screen memories" – and in any case, very early experiences (before age two) – can not be remembered (See the child studies of Eleanor Galenson on "evocative memory").
These techniques are primarily based on conflict theory (see above). As object relations theory evolved, supplemented by the work of Bowlby, Ainsorth, and Beebe, techniques with patients who had more severe problems with basic trust (Erikson, 1950) and a history of maternal deprivation (see the works of Augusta Alpert) led to new techniques with adults. These have sometimes been called interpersonal, intersubjective (cf. Stolorow), relational, or corrective object relations techniques. These techniques include expressing an empathic attunement to the patient or warmth; exposing a bit of the analyst's personal life or attitudes to the patient; allowing the patient autonomy in the form of disagreement with the analyst (cf. I.H. Paul, Letters to Simon.); and explaining the motivations of others which the patient misperceives. Ego psychological concepts of deficit in functioning led to refinements in supportive therapy. These techniques are particularly applicable to psychotic and near-psychotic (cf., Eric Marcus, "Psychosis and Near-psychosis") patients. These supportive therapy techniques include discussions of reality; encouragement to stay alive (including hospitalization); psychotropic medicines to relieve overwhelming depressive affect or overwhelming fantasies (hallucinations and delusions); and advice about the meanings of things (to counter abstraction failures).
The notion of the "silent analyst" has been criticized. Actually, the analyst listens using Arlow's approach as set out in "The Genesis of Interpretation"), using active intervention to interpret resistances, defenses creating pathology, and fantasies. Silence and non-responsiveness was a technique promulgated by Carl Rogers, in his development of so-called "Client Centered Therapy" – and is not a technique of psychoanalysis (also see the studies and opinion papers of Owen Renik, MD). "Analytic Neutrality" is a concept that does not mean the analyst is silent. It refers to the analyst's position of not taking sides in the internal struggles of the patient. For example, if a patient feels guilty, the analyst might explore what the patient has been doing or thinking that causes the guilt, but not reassure the patient not to feel guilty. The analyst might also explore the identifications with parents and others that led to the guilt.
Psychoanalytic constructs have been adapted for use with children with treatments such as play therapy, art therapy, and storytelling. Throughout her career, from the 1920s through the 1970s, Anna Freud adapted psychoanalysis for children through play. This is still used today for children, especially those who are preadolescent (see Leon Hoffman, New York Psychoanalytic Institute Center for Children). Using toys and games, children are able to demonstrate, symbolically, their fears, fantasies, and defenses; although not identical, this technique, in children, is analogous to the aim of free association in adults. Psychoanalytic play therapy allows the child and analyst to understand children's conflicts, particularly defenses such as disobedience and withdrawal, that have been guarding against various unpleasant feelings and hostile wishes. In art therapy, the counselor may have a child draw a portrait and then tell a story about the portrait. The counselor watches for recurring themes — regardless of whether it is with art or toys.
Many studies have also been done on briefer "dynamic" treatments; these are more expedient to measure, and shed light on the therapeutic process to some extent. Brief Relational Therapy (BRT), Brief Psychodynamic Therapy (BPT), and Time-Limited Dynamic Therapy (TLDP) limit treatment to 20-30 sessions. On average, classical analysis may last 5.7 years, but for phobias and depressions uncomplicated by ego deficits or object relations deficits, analysis may run for a shorter period of time. Longer analyses are indicated for those with more serious disturbances in object relations, more symptoms, and more ingrained character pathology (such as obnoxiousness, severe passivity, or heinous procrastination).
Psychoanalytic Training Centers in the United States have been accredited by special committees of the American Psychoanalytic Association or the International Psychoanalytical Association. Because of theoretical differences, other independent institutes arose, usually founded by psychologists, who until 1987 were not permitted access to psychoanalytic training institutes of the American Psychoanalytic Association. Currently there are between seventy-five and one hundred independent institutes in the Unite States. As well, other institutes are affiliated to other organizations such as the American Academy of Psychoanalysis and Dynamic Psychiatry, and the National Association for the Advancement of Psychoanalysis. At most psychoanalytic institutes in the United States, qualifications for entry include a terminal degree in a mental health field, such as Ph.D., C.S.W., or M.D. A few institutes restrict applicants to those already holding an M.D. or Ph.D., and one institute in Southern California confers a Ph.D. or Psy.D. in psychoanalysis upon graduation, which involves completion of the necessary requirements for the state boards that confer that doctoral degree. Some psychoanalytic training has been set up as a post-doctoral fellowship in university settings, such as at Duke University, Yale University, New York University, Adelphi University, and Columbia University. Other psychoanalytic institutes may not be directly associated with universities, but the faculty at those institutes usually hold contemporaneous faculty positions with psychology Ph.D. programs and/or with Medical School psychiatry residency programs.
The International Psychoanalytical Association (IPA) is the world’s primary accrediting and regulatory body for psychoanalysis. Their mission is to assure the continued vigour and development of psychoanalysis for the benefit of psychoanalytic patients. It works in partnership with it’s 70 constituent organizations in 33 countries to support 11,500 members. In the US, there are 77 psychoanalytical organizations, institutes associations in the United States, which are spread across the states of America. The American Psychoanalytical Association (APSaA) has 38 affiliated societies, which are comprised of ten or more active members who practice in a given geographical area. The aims of the APSaA and other psychoanalytical organizations are: provide ongoing educational opportunities for it’s members, stimulate the development and research of psychoanalysis, provide training and organize conferences. There are eight affiliated study groups in the USA (two of them are in Latin America). A study group is the first level of integration of a psychoanalytical body within the International Psychoanalytic Association (IPA), followed by a provisional society and finally a member society.
The Division of Psychoanalysis (39) of the American Psychological Association (APA) was established in the early 1980s by several psychologists, principal among them were Ruben Fine, Ph.D., Robert C. Lane.Ph.D., Max Rosenbaum, Ph.D. Nathan Stockhamer, Ph.D, Helen Block Lewis,Ph.D. and George Goldman, Ph.D. Until the establishment of the Division of Psychoanalysis, psychologists who had trained in independent institutes had no national organization. The Division of Psychoanalysis now has approximately 4,000 members and approximately thirty local chapters in the United States. The Division of Psychoanalysis holds two annual meetings/conferences and offers continuing education in theory, research and clinical technique, as do their affiliated local chapters. The European Psychoanalytical Federation (EPF) is the scientific organization that consolidates all European psychoanalytic societies. This organization is affiliated with the IPA. In 2002 there were approximately 3900 individual members in twenty-two countries, speaking eighteen different languages.12 There are also twenty-five psychoanalytic societies.
Psychoanalysis became popular post-war, as many celebrities found it useful – such as Steve Allen, Jayne Meadows, and Art Buchwald. Psychoanalytic treatment became somewhat less popular during the 1980s and early 1990s. Circa 1986, when insurance companies decimated health insurance coverage for all mental illnesses people for whom psychoanalytic treatment was indicated were increasingly unable to afford it. Gradually, as psychiatry departments became more dependent on grants from pharmaceutical companies, chairs of Psychiatry Departments in the nation's medical schools tended to come from backgrounds involving pharmacological research – not from backgrounds involving analytic training. Interestingly, psychoanalytic institutes have experienced an increase in the number of applicants in recent years, but, not surprisingly, about 70-80% of incoming students are non-MDs.
Over a hundred years of case reports and studies in the journal Modern Psychoanalysis, the Psychoanalytic Quarterly, the International Journal of Psychoanalysis and the Journal of the American Psychoanalytic Association have analyzed efficacy of analysis in cases of neurosis and character or personality problems. Psychoanalysis modified by object relations techniques has been shown to be effective in many cases of ingrained problems of intimacy and relationship (cf. the many books of Otto Kernberg). As a therapeutic treatment, psychoanalytic techniques may be useful in a one-session consultation (see Blackman, J. (1994), Psychodynamic Technique during Ungent Consultation Interviews, Journal Psychotherapy Practice & Research). Psychoanalytic treatment, in other situations, may run from about a year to many years, depending on the severity and complexity of the pathology.
Psychoanalytic theory has, from its inception, been the subject of criticism and controversy. Freud remarked on this early in his career, when other physicians in Vienna ostracized him for his findings that hysterical conversion symptoms were not limited to women. Challenges to analytic theory began with Otto Rank and Adler (turn of the 20th century), continued with behaviorists (e.g. Wolpe) into the 1940s and '50s, and have persisted. Criticisms come from those who object the notion that there are mechanisms, thoughts or feelings in the mind that could be unconscious. Criticisms also have been leveled against the discovery of "infantile sexuality" (the recognition that children between ages two and six imagine things about procreation). Criticisms of theory have led to variations in analytic theories, such as the work of Fairbairn, Balint, and Bowlby. In the past 30 years or so, the criticisms have centered on the issue of empirical verification, in spite of many empirical, prospective research studies that have been empirically validated (e.g., See the studies of Barbara Milrod, at Cornell University Medical School, et al.).
Psychoanalysis has been used as a research tool into childhood development (cf. the journal The Psychoanalytic Study of the Child), and has developed into a flexible, effective treatment for certain mental disturbances (see Wallerstein's (2000) Forty-Two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy). In the 1960s, Freud's early (1905) thoughts on the childhood development of female sexuality were challenged; this challenge led to major research in the 1970s and 80s, and then to a reformulation of female sexual development that corrected some of Freud's concepts.
A 2005 review of randomized controlled trials found that "psychoanalytic therapy is (1) more effective than no treatment or treatment as usual, and (2) more effective than shorter forms of psychodynamic therapy". 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 Recommendation 22 against the use of psychodynamic therapy in cases of schizophrenia, noting that more trials are necessary to verify its effectiveness. However, the PORT recommendation is based on the opinions of clinicians rather than on empirical data, and empirical data exist that contradict 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 that demonstrate that psychodynamic psychotherapy is effective in treating schizophrenia. Dr. Hyman Spotnitz and the practitioners of his theory known as Modern Psychoanalysis, a specific sub-specialty, still report (2007) much success in using their enhanced version of psychoanalytic technique in the treatment of schizophrenia. Further data also suggest that psychoanalysis is not effective (and possibly even detrimental) in the treatment of sex offenders Experiences of psychoanalysts and psychoanalytic psychotherapists and research into infant and child development have led to new insights. Theories have been further developed and the results of empirical research are now more integrated in the psychoanalytic theory.3
There are different forms of psychoanalysis and psychotherapies in which psychoanalytic thinking is practiced. Besides classical psychoanalysis there is for example psychoanalytic psychotherapy. Other examples of well known therapies which also use insights of psychoanalysis are Mentalization-Based Treatment (MBT), and Transference-Focused Psychotherapy (TFP).4 There is also a continuing influence of psychoanalytic thinking in different settings in the mental health care.5 To give an example: in the psychotherapeutic training in the Netherlands, psychoanalytic and system therapeutic theories, drafts, and techniques are combined and integrated. Other psychoanalytic schools include the Kleinian, Lacanian, and Winnicottian schools.
Exchanges between critics and defenders of psychoanalysis have often been so heated that they have come to be characterized as the Freud WarsPopper argued that psychoanalysis is a pseudoscience because its claims are not testable and cannot be refuted, that is, they are not falsifiable. For example, if a client's reaction was not consistent with the psychosexual theory then an alternate explanation would be given (e.g. defense mechanisms, reaction formation).Kraus was the subject of two books written by noted libertarian author Thomas Szasz. Karl Kraus and the Soul Doctors and Anti-Freud: Karl Kraus's Criticism of Psychoanalysis and Psychiatry portrayed Kraus as a harsh critic of Sigmund Freud and of psychoanalysis in general. Other commentators, such as Edward Timms (Karl Kraus - Apocalyptic Satirist) have argued that Kraus respected Freud, though with reservations about the application of some of his theories, and that his views were far less black-and-white than Szasz suggests.
Grünbaum argues that psychoanalytic based theories are falsifiable, but that the causal claims of psychoanalysis are unsupported by the available clinical evidence. Other schools of psychology have produced alternative methods for psychotherapy, including behavior therapy, cognitive therapy, Gestalt therapy and person-centered psychotherapy. Hans Eysenck determined that improvement was no greater than spontaneous remission. Between two-thirds and three-fourths of “neurotics” would recover naturally; this was no different from therapy clients. Prioleau, Murdock, Brody reviewed several therapy-outcome studies and determined that psychotherapy is no different than placebo controls.
Michel Foucault and Gilles Deleuze claimed that the institution of psychoanalysis has become a center of power and that its confessional techniques resemble the Christian tradition. Strong criticism of certain forms of psychoanalysis is offered by psychoanalytical theorists. Jacques Lacan criticized the emphasis of some American and British psychoanalytical traditions on what he has viewed as the suggestion of imaginary "causes" for symptoms, and recommended the return to Freud. Together with Gilles Deleuze, Felix Guattari criticised the Oedipal structure. Luce Irigaray criticised what she called the phallogocentrism of the Freudian and Lacanian psychoanalytical theories.
Due to the wide variety of psychoanalytic theories, varying schools of psychoanalysis often internally criticize each other. One consequence is that some critics offer criticism of specific ideas present only in one or more theories, rather than in all of psychoanalysis while not rejecting other premises of psychoanalysis. Defenders of psychoanalysis argue that many critics (such as feminist critics of Freud) 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. 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 A further consideration with respect to cost is that in circumstances when lower cost treatment is provided to the patient as the analyst is funded by the government, then psychoanalytic treatment occurs at the expense other forms of more effective treatment
The idea of "unconscious" is contested because human behavior can be observed while human psychology has to be guessed at. However, the unconscious is now a hot topic of study in the fields of experimental and social psychology (e.g., implicit attitude measures, fMRI, and PET scans, and other indirect tests). One would be hard pressed to find scientists who still think of the mind as a "black box". Currently, the field of psychology embraces the study of things outside one's awareness. Even strict behaviorists acknowledge that a vast amount of classical conditioning is unconscious and that this has profound effects on our emotional life. The idea of unconscious, and the transference phenomenon, have been widely researched and, it is claimed, validated in the fields of cognitive psychology and social psychology (Westen & Gabbard 2002), though such claims are also contested. Recent developments in neuroscience have resulted in one side arguing that it has provided a biological basis for unconscious emotional processing in line with psychoanalytic theory i.e., neuropsychoanalysis (Westen & Gabbard 2002), while the other side argues that such findings make psychoanalytic theory obsolete and irrelevant.
E. Fuller Torrey, writing in Witchdoctors 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 (p. 76). Some scientists regard psychoanalysis as a pseudoscience (Cioffi, 1998). Among philosophers, Karl Popper argued that Freud's theory of the unconscious was not falsifiable and therefore not scientific. Popper did not object to the idea that some mental processes could be unconscious but to investigations of the mind that were not falsifiable. In other words, if it were possible to connect every conceivable experimental outcome with Freud's theory of the unconscious mind, then no experiment could refute the theory. Anthropologist Roy Wagner, in The Invention of Culture, ridicules psychoanalysis and tries to account for personality and emotional disorder in terms of invention and convention.
Some proponents of psychoanalysis suggest that its concepts and theories are more akin to those found in the humanities than those proper to the physical and biological/medical 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. Despite criticism regarding the validity of psychoanalytic therapeutic technique, numerous outcome studies have shown that its efficacy is equal to that of other mainstream therapy modalities such as cognitive-behavioral therapy (see Horvath, A. (2001) The Alliance. Psychotherapy: Theory, research, practice, training. Vol. 38 (pp. 365-372).
Jacques Derrida incorporated aspects of psychoanalytic theory into deconstruction in order to question what he called the 'metaphysics of presence'. Freud's insistence, in the first chapter of The Ego and the Id, that philosophers will recoil from his theory of the unconscious is clearly a forbear to Derrida's understanding of metaphysical 'self-presence'. Derrida also turns some of these ideas against Freud, to reveal tensions and contradictions in his work. These tensions are the conditions upon which Freud's work can operate. For example, although Freud defines religion and metaphysics as displacements of the identification with the father in the resolution of the Oedipal complex, Derrida insists in The Postcard: From Socrates to Freud and Beyond that the prominence of the father in Freud's own analysis is itself indebted to the prominence given to the father in Western metaphysics and theology since Plato. Thus Derrida thinks that even though Freud remains within a theologico-metaphysical tradition of 'phallologocentrism', Freud nonetheless criticizes that tradition.
The purpose of Derrida's analysis is not to refute Freud, which would only reaffirm traditional metaphysics, but to reveal an undecidability at the heart of his project. This deconstruction of Freud casts doubt upon the possibility of delimiting psychoanalysis as a rigorous science. Yet it celebrates the side of Freud which emphasises the open-ended and improvisatory nature of psychoanalysis, and its methodical and ethical demand that the testimony of the analysand should be given prominence in the practice of analysis. Psychoanalysis, or at least the dominant version of it, has been denounced as patriarchal or phallocentric by some proponents of feminist theory. Other feminist scholars have argued that Freud opened up society to female sexuality.
2 Mitchell, S.A., & Black, M.J. (1995). Freud and beyond: a history of modern psychoanalytic thought. Basic Books, New York. xviii-xx.
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