Psychoanalyzing

	The words "Die Psychoanalyse" in Sigmund Freud's handwriting, 1938
ICD-9-CM	94.31
MeSH	D011572
	[edit on Wikidata

Psychoanalysis^[i] is a set of theories and therapeutic techniques^[ii] that deal in part with the unconscious mind,^[iii] and which together form a method of treatment for mental disorders. The discipline was established in the early 1890s by Sigmund Freud,^[1] whose work stemmed partly from the clinical work of Josef Breuer and others. Freud developed and refined the theory and practice of psychoanalysis until his death in 1939. In an encyclopedic article, he identified the cornerstones of psychoanalysis as "the assumption that there are unconscious mental processes, the recognition of the theory of repression and resistance, the appreciation of the importance of sexuality and of the Oedipus complex."^[2] Freud's colleagues Alfred Adler and Carl Gustav Jung developed offshoots of psychoanalysis which they called individual psychology (Adler) and analytical psychology (Jung), although Freud himself wrote a number of criticisms of them and emphatically denied that they were forms of psychoanalysis.^[3] Psychoanalysis was later developed in different directions by neo-Freudian thinkers, such as Erich Fromm, Karen Horney, and Harry Stack Sullivan.^[4]

Freud distinguished between the conscious and the unconscious mind, arguing that the unconscious mind largely determines behaviour and cognition owing to unconscious drives. Freud observed that attempts to bring such drives into awareness triggers resistance in the form of defense mechanisms, particularly repression, and that conflicts between conscious and unconscious material can result in mental disturbances. He also postulated that unconscious material can be found in dreams and unintentional acts, including mannerisms and Freudian slips. Psychoanalytic therapy, or simply analytical therapy,^[5] developed as a means to improve mental health by bringing unconscious material into consciousness. Psychoanalysts place a large emphasis on early childhood in an individual's development. During therapy, a psychoanalyst aims to induce transference, whereby patients relive their infantile conflicts by projecting onto the analyst feelings of love, dependence and anger.^[6]^[7]

During psychoanalytic sessions a patient traditionally lies on a couch, and an analyst sits just behind and out of sight. The patient expresses their thoughts, including free associations, fantasies, and dreams, from which the analyst infers the unconscious conflicts causing the patient's symptoms and character problems. Through the analysis of these conflicts, which includes interpreting the transference and countertransference (the analyst's feelings for the patient), the analyst confronts the patient's pathological defence mechanisms to help patients understand themselves better.^[8]

Psychoanalysis is a controversial discipline, and its effectiveness as a treatment has been contested, although it retains influence within psychiatry.^[iv]^[v] Psychoanalytic concepts are also widely used outside the therapeutic arena, in areas such as psychoanalytic literary criticism and film criticism, analysis of fairy tales, philosophical perspectives such as Freudo-Marxism, and other cultural phenomena.

History

1890s

The idea of psychoanalysis (German: Psychoanalyse) first began to receive serious attention under Sigmund Freud, who formulated his own theory of psychoanalysis in Vienna in the 1890s. Freud was a neurologist trying to find an effective treatment for patients with neurotic or hysterical symptoms. Freud realised that there were mental processes that were not conscious whilst he was employed as a neurological consultant at the Children's Hospital, where he noticed that many aphasic children had no apparent organic cause for their symptoms. He then wrote a monograph about this subject.^[9] In 1885, Freud obtained a grant to study with Jean-Martin Charcot, a famed neurologist, at the Salpêtrière in Paris, where he followed the clinical presentations of Charcot, particularly in the areas of hysteria, paralyses and the anaesthesias. Charcot had introduced hypnotism as an experimental research tool and developed photographic representation of clinical symptoms.

Freud's first theory to explain hysterical symptoms was presented in Studies on Hysteria (1895; Studien über Hysterie), co-authored with his mentor the distinguished physician Josef Breuer, which was generally seen as the birth of psychoanalysis.^[10] The work was based on Breuer's treatment of Bertha Pappenheim, referred to in case studies by the pseudonym "Anna O.", treatment which Pappenheim herself had dubbed the "talking cure". Breuer wrote that many factors could result in such symptoms, including various types of emotional trauma, and he also credited work by others such as Pierre Janet; while Freud contended that at the root of hysterical symptoms were repressed memories of distressing occurrences, almost always having direct or indirect sexual associations.^[10]

Around the same time, Freud attempted to develop a neuro-physiological theory of unconscious mental mechanisms, which he soon gave up. It remained unpublished in his lifetime.^[11] The term 'psychoanalysis' (psychoanalyse) was first introduced by Freud in his essay titled "Heredity and etiology of neuroses" ("L'hérédité et l'étiologie des névroses"), written and published in French in 1896.^[12]^[13]

In 1896, Freud also published his seduction theory, claiming to have uncovered repressed memories of incidents of sexual abuse for all his current patients, from which he proposed that the preconditions for hysterical symptoms are sexual excitations in infancy.^[14] Though in 1896 he had reported that his patients "had no feeling of remembering the scenes", and assured him "emphatically of their unbelief",^[14]^: 204 in later accounts he claimed that they had told him that they had been sexually abused in infancy. By 1898 he had privately acknowledged to his friend and colleague Wilhelm Fliess that he no longer believed in his theory, though he did not state this publicly until 1906.^[15]

Building on his claims that the patients reported infantile sexual abuse experiences, Freud subsequently contended that his clinical findings in the mid-1890s provided evidence of the occurrence of unconscious fantasies, supposedly to cover up memories of infantile masturbation.^[15] Only much later did he claim the same findings as evidence for Oedipal desires.^[16] In the latter part of the 20th century, several Freud scholars challenged Freud's perception of the patients who informed him of childhood sexual abuse, arguing that he had imposed his preconceived notions on his patients.^[17]^[18]^[19]

By 1899, Freud had theorised that dreams had symbolic significance and generally were specific to the dreamer. Freud formulated his second psychological theory—that the unconscious has or is a "primary process" consisting of symbolic and condensed thoughts, and a "secondary process" of logical, conscious thoughts. This theory was published in his 1899 book, The Interpretation of Dreams, which Freud thought of as his most significant work.^[20]^[21] Freud outlined a new topographic theory, which theorised that unacceptable sexual wishes were repressed into the "System Unconscious". These wishes were made unconscious due to society's condemnation of premarital sexual activity, and this repression created anxiety. This "topographic theory" is still popular in much of Europe, although it has fallen out of favour in much of North America, where it has been largely supplanted by structural theory.^[22] In addition, The Interpretation of Dreams contained Freud's first conceptualisation of the Oedipal complex, which asserted that young boys are sexually attracted to their mothers and envious of their fathers for being able to have sex with their mothers.

Psychologist Frank Sulloway in his book Freud, Biologist of the Mind: Beyond the Psychoanalytic Legend argues that Freud's biological theories like libido were rooted in the biological hypothesis that accompanied the work of Charles Darwin, citing theories of Krafft-Ebing, Molland, Havelock Ellis, Haeckel, Wilhelm Fliess as influencing Freud.^[23]^: 30

1900–1940s

In 1905, Freud published Three Essays on the Theory of Sexuality in which he laid out his discovery of the psychosexual phases, which categorised early childhood development into five stages depending on what sexual affinity a child possessed at the stage:^[24]

Oral (ages 0–2);
Anal (2–4);
Phallic-oedipal or First genital (3–6);
Latency (6–puberty); and
Mature genital (puberty–onward).

His early formulation included the idea that because of societal restrictions, sexual wishes were repressed into an unconscious state, and that the energy of these unconscious wishes could be result in anxiety or physical symptoms. Early treatment techniques, including hypnotism and abreaction, were designed to make the unconscious conscious in order to relieve the pressure and the apparently resulting symptoms. This method would later on be left aside by Freud, giving free association a bigger role.

In On Narcissism (1915), Freud turned his attention to the titular subject of narcissism.^[25] Freud characterized the difference between energy directed at the self versus energy directed at others using a system known as cathexis. By 1917, in "Mourning and Melancholia", he suggested that certain depressions were caused by turning guilt-ridden anger on the self.^[26] In 1919, through "A Child is Being Beaten", he began to address the problems of self-destructive behavior and sexual masochism.^[27] Based on his experience with depressed and self-destructive patients, and pondering the carnage of World War 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 in Group Psychology and the Analysis of the Ego.^[28]^[29] In that same year, Freud suggested his dual drive theory of sexuality and aggression in Beyond the Pleasure Principle, to try to begin to explain human destructiveness. Also, it was the first appearance of his "structural theory" consisting of three new concepts id, ego, and superego.^[30]

Three years later, in 1923, he summarised the ideas of id, ego, and superego in The Ego and the Id.^[31] In the book, 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. Hence, Freud characterised repression as both a cause and a result of anxiety. In 1926, in "Inhibitions, Symptoms and Anxiety", Freud characterised how intrapsychic conflict among drive and superego caused anxiety, and how that anxiety could lead to an inhibition of mental functions, such as intellect and speech.^[32] In 1924, Otto Rank published The Trauma of Birth, which analysed culture and philosophy in relation to separation anxiety which occurred before the development of an Oedipal complex.^[33] Freud's theories, however, characterized no such phase. According to Freud, the Oedipus complex was at the centre of neurosis, and was the foundational source of all art, myth, religion, philosophy, therapy—indeed of all human culture and civilization. It was the first time that anyone in Freud's inner circle had characterised something other than the Oedipus complex as contributing to intrapsychic development, a notion that was rejected by Freud and his followers at the time.

By 1936 the "Principle of Multiple Function" was clarified by Robert Waelder.^[34] 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, anxiety, reality, and defenses. Also in 1936, Anna Freud, Sigmund's daughter, published her seminal book, The Ego and the Mechanisms of Defense, outlining numerous ways the mind could shut upsetting things out of consciousness.^[35]

1940s–present

When Hitler's power grew, the Freud family and many of their colleagues fled to London. Within a year, Sigmund Freud died.^[36] In the United States, also following the death of Freud, a new group of psychoanalysts began to explore the function of the ego. Led by Heinz Hartmann, the group built upon understandings of the synthetic function of the ego as a mediator in psychic functioning, distinguishing such from autonomous ego functions (e.g. memory and intellect). These "ego psychologists" of the 1950s paved a way to focus analytic work by attending to the defenses (mediated by the ego) before exploring the deeper roots to the unconscious conflicts.

In addition, there was growing interest in child psychoanalysis. Psychoanalysis has been used as a research tool into childhood development,^[vi] and is still used to treat certain mental disturbances.^[37] In the 1960s, Freud's early thoughts on the childhood development of female sexuality were challenged; this challenge led to the development of a variety of understandings of female sexual development,^[38] many of which modified the timing and normality of several of Freud's theories. Several researchers followed Karen Horney's studies of societal pressures that influence the development of women.^[39]

In the first decade of the 21st century, there were approximately 35 training institutes for psychoanalysis in the United States accredited by the American Psychoanalytic Association (APsaA), which is a component organization of the International Psychoanalytical Association (IPA), and there are over 3000 graduated psychoanalysts practicing in the United States. The IPA accredits psychoanalytic training centers through such "component organisations" throughout the rest of the world, including countries such as Serbia, France, Germany, Austria, Italy, Switzerland,^[40] and many others, as well as about six institutes directly in the United States.

Psychoanalysis as a movement

Freud founded the Psychological Wednesday Society in 1902, which Edward Shorter argues was the beginning of psychoanalysis as a movement. This society became the Vienna Psychoanalytic Society in 1908 in the same year as the first international congress of psychoanalysis held in Salzburg, Austria.^[41]^: 110 Alfred Adler was one of the most active members in this society in its early years.^[42]^: 584

The second congress of psychoanalysis took place in Nuremberg, Germany in 1910.^[41]^: 110 At this congress, Ferenczi called for the creation of an International Psychoanalytic Association with Jung as president for life.^[43]^: 15 A third congress was held in Weimar in 1911.^[41]^: 110 The London Psychoanalytical Society was founded in 1913 by Ernest Jones.^[44]

Developments of alternative forms of psychotherapy

Cognitive behavioural therapy (CBT)

In the 1950s, psychoanalysis was the main modality of psychotherapy. Behavioural models of psychotherapy started to assume a more central role in psychotherapy in the 1960s.^[vii]^[45] Aaron T. Beck, a psychiatrist trained in a psychoanalytic tradition, set out to test the psychoanalytic models of depression empirically and found that conscious ruminations of loss and personal failing were correlated with depression. He suggested that distorted and biased beliefs were a causal factor of depression, publishing an influential paper in 1967 after a decade of research using the construct of schemas to explain the depression.^[45]^: 221 Beck developed this empirically supported hypothesis for the cause of depression into a talking therapy called cognitive behavioral therapy (CBT) in the early 1970s.

Attachment theory

Attachment theory was developed theoretically by John Bowlby and formalized empirically by Mary Ainsworth.^[46] Bowlby was trained psychoanalytically but was concerned about some properties of psychoanalysis;^[47]^: 23 he was troubled by the dogmatism of psychoanalysis at the time, its arcane terminology, the lack of attention to environment in child behaviour, and the concepts derived from talking therapy to child behaviour.^[47]^: 23 In response, he developed an alternative conceptualization of child behaviour based on principles on ethology.^[47]^: 24 Bowlby's theory of attachment rejects Freud's model of psychosexual development based on the Oedipal model.^[47]^: 25 For his work, Bowlby was shunned from psychoanalytical circles who did not accept his theories. Nonetheless, his conceptualization was adopted widely by mother-infant research in the 1970s.^[47]^: 26

Theories

The predominant psychoanalytic theories can be organised into several theoretical schools. Although these perspectives differ, most of them emphasize the influence of unconscious elements on the conscious. There has also been considerable work done on consolidating elements of conflicting theories.^[48]

There are some persistent conflicts among psychoanalysts regarding specific causes of certain syndromes, and some disputes regarding the ideal treatment techniques. In the 21st century, psychoanalytic ideas have found influence in fields such as childcare, education, literary criticism, cultural studies, mental health, and particularly psychotherapy. Though most mainstream psychoanalysts subscribe to modern strains of psychoanalytical thought, there are groups who follow the precepts of a single psychoanalyst and their school of thought. Psychoanalytic ideas also play roles in some types of literary analysis such as archetypal literary criticism.^[49]

Topographic theory

Topographic theory was named and first described by Sigmund Freud in The Interpretation of Dreams (1899).^[50] The theory hypothesizes that the mental apparatus can be divided into the systems Conscious, Preconscious, and Unconscious. 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.^[51]

Structural theory

Structural theory divides the psyche into the id, the ego, and the super-ego. The id is present at birth as the repository of basic instincts, which Freud called "Triebe" ("drives"). Unorganized and unconscious, it operates merely on the 'pleasure principle', without realism or foresight. The ego develops slowly and gradually, being concerned with mediating between the urging of the id and the realities of the external world; it thus operates on the 'reality principle'. The super-ego is held to be the part of the ego in which self-observation, self-criticism and other reflective and judgmental faculties develop. The ego and the super-ego are both partly conscious and partly unconscious.^[51]

Theoretical and clinical approaches

During the twentieth century, many different clinical and theoretical models of psychoanalysis emerged.

Ego psychology

Ego psychology was initially suggested by Freud in Inhibitions, Symptoms and Anxiety (1926),^[32] while major steps forward would be made through Anna Freud's work on defense mechanisms, first published in her book The Ego and the Mechanisms of Defence (1936).^[35]

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.^[52]

Frosch (1964) described differences in those people who demonstrated damage to their relationship to reality, but who seemed able to test it.^[53]

According to ego psychology, ego strengths, later described by Otto F. 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.^[54] Synthetic functions, in contrast to autonomous functions, arise from the development of the ego and serve the purpose of managing conflict processes. Defenses are synthetic functions that protect the conscious mind from awareness of forbidden impulses and thoughts. One purpose of ego psychology has been to emphasize that some mental functions can be considered to be basic, rather than derivatives of wishes, affects, or defenses. However, autonomous ego functions can be secondarily affected because of unconscious conflict.^[55] 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 mental processes. There are six "points of view", five described by Freud and a sixth added by Hartmann. Unconscious processes can therefore be evaluated from each of these six points of view:^[56]

Topographic
Dynamic (the theory of conflict)
Economic (the theory of energy flow)
Structural
Genetic (i.e. propositions concerning origin and development of psychological functions)
Adaptational (i.e. psychological phenomena as it relates to the external world)

Modern conflict theory

Modern conflict theory, a variation of ego psychology, is a revised version of structural theory, most notably different by altering concepts related to where repressed thoughts were stored.^[31]^[32] Modern conflict theory addresses emotional symptoms and character traits as complex solutions to mental conflict.^[57] It dispenses with the concepts of a fixed id, ego and superego, and instead posits conscious and unconscious 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 objective of modern conflict-theory psychoanalysis is to change the balance of conflict in a patient by 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 who follow the work of Charles Brenner, especially The Mind in Conflict (1982), include Sandor Abend,^[58] Jacob Arlow,^[59] and Jerome Blackman.^[60]

Object relations theory

Object relations theory attempts to explain human relationships through a study of how mental representations of the self and others are organized.^[61] The clinical symptoms that suggest object relations problems (typically 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 significant others.

Klein discusses the concept of introjection, creating a mental representation of external objects; and projection, applying this mental representation to reality.^[62]^: 24 Wilfred Bion introduced the concept of containment of projections in the mother-child relationship where a mother understands an infants projections, modifies them and returns them to the child.^[62]^: 27

Concepts regarding internal representation (aka 'introspect', 'self and object representation', or 'internalization of self and other'), although often attributed to Melanie Klein, were actually first mentioned by Sigmund Freud in his early concepts of drive theory (Three Essays on the Theory of Sexuality, 1905). 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.^[26]

Melanie Klein's hypotheses regarding internalization during the first year of life, leading to paranoid and depressive positions, were later challenged by René 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. Mahler, Fine, and Bergman (1975) describe 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, internalizations, stability of affect management, and ability to develop healthy autonomy.^[63]

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, Identity, Closeness, and Stability) in relationships, the teenager must resolve the problems with identity and redevelop self and object constancy.^[60]

Self psychology

Self psychology emphasizes the development of a stable and integrated sense of self through empathic contacts with other humans, primary significant others conceived of as 'selfobjects'. Selfobjects meet the developing self's needs for mirroring, idealization, and twinship, and thereby strengthen the developing self. The process of treatment proceeds through "transmuting internalizations" in which the patient gradually internalizes the selfobject functions provided by the therapist.

Self psychology was proposed originally by Heinz Kohut, and has been further developed by Arnold Goldberg, Frank Lachmann, Paul and Anna Ornstein, Marian Tolpin, and others.

Lacanian psychoanalysis

Lacanian psychoanalysis, which integrates psychoanalysis with structural linguistics and Hegelian philosophy, is especially popular in France and parts of Latin America. Lacanian psychoanalysis is a departure from the traditional British and American psychoanalysis. Jacques Lacan frequently used the phrase "retourner à Freud" ("return to Freud") in his seminars and writings, 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 and also claims the necessity of reading Freud's complete works, not only a part of them. Lacan's concepts concern the "mirror stage", the "Real", the "Imaginary", and the "Symbolic", and the claim that "the unconscious is structured as a language."^[64]

Though a major influence on psychoanalysis in France and parts of Latin America, Lacan and his ideas have taken longer to be translated into English and he has thus had a lesser impact on psychoanalysis and psychotherapy in the English-speaking world. In the United Kingdom and the United States, his ideas are most widely used to analyze texts in literary theory.^[65] Due to his increasingly critical stance towards the deviation from Freud's thought, often singling out particular texts and readings from his colleagues, Lacan was excluded from acting as a training analyst in the IPA, thus leading him to create his own school in order to maintain an institutional structure for the many candidates who desired to continue their analysis with him.^[66]

Adaptive paradigm

The adaptive paradigm of psychotherapy develops out of the work of Robert Langs. The adaptive paradigm interprets psychic conflict primarily in terms of conscious and unconscious adaptation to reality. Langs' recent work in some measure returns to the earlier Freud, in that Langs prefers a modified version of the topographic model of the mind (conscious, preconscious, and unconscious) over the structural model (id, ego, and super-ego), including the former's emphasis on trauma (though Langs looks to death-related traumas rather than sexual traumas).^[51] At the same time, Langs' model of the mind differs from Freud's in that it understands the mind in terms of evolutionary biological principles.^[67]

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