Book: Psychotherapy: A Very Short Introduction (Very Short Introductions)

Previous: Chapter 2: Freud and psychoanalysis
Next: Chapter 4: Time-limited psychotherapy

The early development of psychoanalysis was a period of intense intellectual ferment. Freud’s ideas were evolving rapidly and he collected a glittering group of followers. Initially they were all men; creative, self-confident, and argumentative. They rapidly began to generate their own ideas, often falling out with each other, and several split from Freud. The first to leave the group was Alfred Adler, but the most acrimonious and influential split was with Carl Jung.

Carl Gustav Jung

Jung was the first non-Jewish psychoanalyst and the first one not from Vienna. He lived in Switzerland working as a psychiatrist with Manfred Bleuler, the psychiatrist who introduced the term schizophrenia. Jung was twenty years younger than Freud, tall and wealthy, and their relationship was very intense until it soured.

Jung had always been somewhat mystical. Unlike Freud he came from a religious family, and his earliest interest had been in paranormal phenomena. He eventually fell out with Freud over what he saw as Freud’s excessive emphasis on the role of the sex drive, but also more generally as a reaction to Freud’s unremittingly rational approach. Jung was fundamentally a romantic individual who believed that analysis had the potential to bring patients to an emotionally richer, more spiritual state.

Jung’s constant striving for something more, and his dissatisfaction with the mundane, characterized both his thinking and his life. He broke sexual boundaries with patients and during a particularly turbulent period he probably tipped over into a brief psychosis. Despite all this (or perhaps because of it) he was enormously productive and creative. He introduced the concepts of introvert and extrovert, but he is probably best known for his ideas on symbolism.

Jung took a radically different approach to the unconscious material that patients reported in their analyses. He was one of the few early psychoanalysts who worked in a psychiatric hospital, and had noticed similarities with the hallucinations described by psychotic patients. He observed regularly recurring images of easily identified figures, such as that of a wise old man, a warm motherly figure, God, and the Devil. Freud thought of these as distortions caused by neurotic conflicts, but Jung believed they were fundamental to human thinking. He called them archetypes, and believed that they could be found in all cultures and all times. He concluded that we access them from a collective unconscious, a folk memory that we are all born with and which shapes us.

Prominent archetypes include the anima (the feminine side of men), the persona (the face we present to the world), and the imago (our ideal self). The shadow is particularly important in Jungian thinking. It contains all our most shameful and frightening experiences, thoughts, and feelings—those that we keep hidden both from ourselves and from others. Jung thought that our shadow grew stronger and more threatening the longer it was ignored (like Oscar Wilde’s ageing portrait of Dorian Gray). For us to develop healthily it needed to be brought into the daylight and confronted.

Jungian psychotherapy is called analytical psychology to distinguish it from psychoanalysis. It is shorter, usually with weekly sessions for a year or so, and there is no analytical couch. Therapist and patient sit facing each other and therapy is much more focused on the here-and-now. Analytical psychology aims for integration of the personality, aspiring to a harmony which accepts inherent contradictions rather than striving to reduce or eradicate them. As in classical analysis, the initial sessions involve an exploration of early experiences, and dreams are also taken very seriously. However, this early exploration is soon brought to bear in understanding current experiences and problems. In sharp contrast to psychoanalysis, dreams are taken at face value with no tortuous extraction of latent from manifest content.

While Freud was fairly modest in his aims for therapy (‘to convert your neurotic anxiety into day-to-day misery’), Jung believed it could make us better people. His emphasis on personal integration, his preoccupation with symbols and Eastern mysticism (see ), and his tolerance of uncertainty, have meant that Jungian psychotherapy is particularly attractive to creative and artistic individuals and also to people later in life.

Freud thought that we become less able to utilize psychotherapy with increasing age, because we become more rigid. Jung, on the contrary, believed that the wealth of life experience older people bring makes them eminently suitable for psychotherapy. Jungian psychotherapy provides opportunities to make sense of life and come to terms with ourselves and our approaching mortality. Because of its tolerance of ambiguity and mystery, it is often experienced as richer and more tolerant than analysis.

Alfred Adler and the neo-Freudians

Alfred Adler was one of Freud’s original inner circle. Although also a Viennese Jew he was very different from Freud. He came from a large Hungarian family (Vienna was still the capital of the Austro-Hungarian Empire) and was short and physically unimposing. His politics were radical and his personal habits chaotic. His lasting contribution to psychotherapy is the inferiority complex. He also thought that Freud overemphasized the sexual, and believed that what drove most of us was a struggle to overcome a sense of personal inferiority, whether real or imagined.

image

6. The mandala—an Eastern spiritual symbol of the universe and wholeness. Jung wrote in his memoirs: ‘I sketched every morning in a notebook a small circular drawing … and discovered what the mandala really is: … the Self, the wholeness of the personality, which if all goes well is harmonious’

Adler was very energetic and forthright. He actively spread his ideas throughout workers’ education movements, schools, and various other institutions. He situated the patient firmly as a whole person in his social context, and believed that you had to understand this context in order to understand the individual. He often interviewed family members and encouraged frank exchanges between them. Many of his ideas about social inclusion and the power imbalances in society (especially that between the sexes) seem strikingly modern. He saw neurotic symptoms as barriers to achievement and self-fulfilment, and would often start his therapies with the question ‘If you didn’t have this problem, what would you be doing?’

Neo-Freudians

Adler moved to the US in 1930 and was followed by many Jewish psychoanalysts fleeing the Nazis. These arriving analysts were exposed to a dramatically different lifestyle in America and were taken aback by it. The impact of culture and the wider society on them and on their patients was revelatory. The effects of society and culture in shaping patients’ aspirations, their values, and also their neuroses could not be ignored. Neo-Freudian practice and writing embraced a broader, more interpersonal, perspective.

This attention to social factors in psychotherapy was not a trivial departure. Karen Horney, an early member of the group, challenged the entrenched gender stereotypes of psychoanalysis, as have many feminists since. She attacked its prejudices against women and the demeaning concept of ‘penis envy’. She even argued that male ambition and competitiveness were themselves a form of envy, an envy of women’s innate creativity in giving birth. The shift in thinking was profound.

Psychotherapy was becoming firmly located as an interpersonal activity. Its focus was moving to the current interactions between the patient and the individuals who mattered to them. Painful memories from the family past were no longer the whole story. Just as a patient’s relationships determined their well-being, so their interaction with the therapist became key to successful psychotherapy. These interactions were seen as agents of change in themselves, not simply tools to understand intrapsychic events. Another in this group, Harry Stack Sullivan, declared that psychotherapy should ‘focus on the interactional, not the intrapsychic’. Therapists should pay attention to the real events in their patients’ lives (which he called ‘problems in living’), not just to patients’ interpretations of them. For later existential therapists such as Irving Yalom () the relationship itself came to be seen as curative.

Erik Erikson

The neo-Freudians had initiated a process that would, in time, lead to counselling and person-centred therapy. Erik Erikson helped set this transformation on its way by radically rethinking the maturational crises we experience in our lives. He proposed that we continue to face new challenges to our sense of identity throughout our lives, calling them the eight stages of development. Problems can arise at any of these stages, even if earlier ones have been resolved perfectly well. For example, Erikson believed that we can develop serious psychological disturbances when confronted by a crisis such as a serious illness, despite having been perfectly well adjusted previously. This is in stark contrast to traditional analytical thinking where such late-onset psychological crises are explained as reactivations of unresolved earlier conflicts.

Erikson, despite his name, was also a German-speaking Jewish analyst from Vienna. He was tall, blond, blue-eyed, and had been taunted from an early age from both sides (Aryans about his Jewishness, Jews about his Aryan looks). His work reflects this experience. His eight stages in life each present us with a potential identity crisis (). Each of these identity crises contains two opposites that have to be recognized and accepted, with both making their unique contribution to who we are.

Box 1 Erikson’s stages of psychosocial (ego) development

Completed Failed Age
Trust Mistrust 0–1 years
Autonomy Shame 1–3 years
Purpose–initiative Guilt 3–6 years
Competence–industry Inferiority 6–11 years
Fidelity–identity Role confusion 12–18 years
Intimacy Isolation 18–35 years
Generativity Stagnation 35–64 years
Ego integrity Despair 65 years onwards

Obviously these ages are just rough indications. Erikson’s stages provide a structure for understanding problems that takes age and experience into consideration, and even later challenges and stages have been added more recently to his original eight in response to working with our increasingly ageing population. Erikson did believe, like Freud, that getting stuck in personal development later in life was more likely if earlier conflicts had not been resolved. However, he also believed we could break down later in life, even if all the earlier conflicts had been surmounted. For instance, a successful and well-balanced man who has been enormously productive in his career might still struggle with the end of that career. His ‘generativity’ may become eroded by the ‘stagnation’ in his leadership position.

Daniel Stern, an American analyst and researcher, came to an intermediate position, based on close observations of mothers and babies. He described different domains in the development of our sense of self. He viewed each of these domains as tasks for life that are never fully resolved, and so we revisit them repeatedly. Like Erikson, he also stressed the importance of attending to the ‘present moment’, in therapy as in all our relationships.

Shell shock in World War I

There is a clear intellectual thread running from Jung to the neo-Freudians. Practice steadily shifts away from a tight focus on what is going on in the patient’s mind and its origins in very early experiences. The interest settles more on what is happening right now, both between the patient and the therapist, and also more widely in the patient’s life. These were, however, not the first variations in Freudian practice. During World War I, psychotherapy came into its own during the treatment of shell-shocked soldiers (), although the military psychiatrists using it did not have much time left over for writing up their theories.

World War I produced an enormous number of psychological casualties. This was mainly because of its special nature—months of waiting around in trenches, always on edge for the next sniper bullet or shell to land. Most soldiers had only a limited education and were psychologically unsophisticated. Many developed what we now easily recognize as hysterical disorders—uncontrollable shaking, paralyses, and nightmares that made them unfit to fight. These conditions became severe and chronic because they were unable to make the link between the onset of their symptoms and the very understandable terror they were experiencing.

A slimmed down and modified Freudian approach was rapidly developed for treating shell shock. This abandoned Freud’s sexual theorizing and focused on emotional conflict. Symptoms originated from the soldier’s sense of duty and his ‘unacceptable’ (and thus repressed) desire to escape the horror of his current situation. Like the later neo-Freudians, the army doctors worked towards rapidly uncovering these repressed desires and fears. However, they were not interested in, nor did they have time for, fine details. They relied heavily on their status and force of personality to reassure and encourage their patients, often using simple hypnosis to strengthen suggestions. An important feature of this rough and ready psychotherapy was normalizing the experience for the soldiers and protecting their self-respect.

image

7. The great numbers of soldiers who developed shell shock in the trenches demonstrated that psychological stress could cause breakdowns and psychological treatments were needed to help them

This down-to-earth and more supportive analytic relationship features widely in novels, but has received relatively little attention in psychotherapy literature. It demonstrated a pragmatic and self-confident approach by doctors familiar with Freud’s and Jung’s psychodynamic thinking.

Attachment theory

A similar leap forward occurred after World War II, with the creation of attachment theory, proposed by John Bowlby. Bowlby was an analyst familiar with the work of leading animal behaviourists. He had been sent away early to boarding school by his rather cold, upper-class family, and was acutely sensitive to the importance of separation for young children. He undertook groundbreaking investigations into the lives of displaced children in the aftermath of the war.

In his highly influential book Maternal Care and Mental Health, Bowlby stressed the importance of a consistent and warm early bond with the mother for emotional development. His insights have revolutionized the care of children in day nurseries and hospitals across the world. He emphasized the importance of the quality of this real relationship rather than the infant’s fantasies about it—such as the real experience of abandonment, deliberate or otherwise—and this initially made him unpopular with analysts.

His concept of secure and insecure attachments, which provide us with internal working models for subsequent relationships, is now widely accepted. The sense of security experienced in therapy is now seen as a reparative experience, one that has some potential to make up for an earlier inadequate attachment. It sees the secure attachment to the therapist as a healing factor in its own right. Cure does not come exclusively from intellectual insights enabling the working through of earlier conflicts. These conflicts may simply lose some of their power as a direct consequence of this new healing experience.

Donald Winnicott was a prominent psychoanalyst and paediatrician who also linked actual events and experiences in real relationships with our personal development. He introduced two influential new ideas. The first was that of the good-enough mother. She should not be too perfect or there would be no scope for spontaneity and change. Equally, she should not be too chaotic or there would not be sufficient security and containment for emotional growth. Being ‘good enough’ means accepting those natural flaws and minor failures, which we all need to learn to tolerate and master. His second idea was the false self that a child might develop in response to a mother or carer whose own needs are too strong and intrusive. If this happens then a false self, which is often overly mature and seemingly self-confident, is presented to the world like a shield. A consequence is that the true self becomes isolated from experience and is deprived of opportunities to develop fully.

These developments may seem a bit academic, but they have had an enormous influence on psychotherapy and more widely on how we manage our personal and family relationships. What is characteristic of all of them is the elevation of the importance of real experiences in the process of psychotherapy. The reality of the mothering experience matters as much as, if not more than, any fantasies and conflicts surrounding it. What sort of life the patient is living now also matters—whether or not she has the potential to establish and maintain close and fulfilling relationships.

Lastly, the tone of the psychotherapy matters, not just its success in the technicalities of uncovering conflicts or interpreting defences. The psychoanalyst Nina Coltart stressed how ‘people not only like, but need, to tell their stories, especially to an attentive listener equipped with certain skills’, someone who ‘listens in a particular way’. Freud believed that the analyst should be a neutral figure, and that any transference was to be understood and interpreted away. Now it is no longer considered a failure of therapy if the patient comes away with a fond memory of the process and a genuine affection for their analyst.

Psychotherapy has moved permanently away from the caricature of an exciting, intellectual detective story, tracking down and unearthing the hidden cause of problems. The relationship itself matters. The therapy relationship is usually experienced as warm and positive, but it is most emphatically not just that. The therapist’s job is to use it to work with relationship patterns and behaviours, many of which may be quite painful. Analysts still insist that the treatment should not be too comfortable—patients have to confront difficult issues. However, virtually all psychotherapists now recognize that the quality of the relationship matters in its own right and is a major part of the cure. In all of the therapies described in the following chapters you will see this understanding run through their practice.

Previous: Chapter 2: Freud and psychoanalysis
Next: Chapter 4: Time-limited psychotherapy