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

Previous: Chapter 1: What is psychotherapy and who is it for?
Next: Chapter 3: Post-Freudians: moving towards the interpersonal

Almost all modern psychotherapies owe their origins to Freud and psychoanalysis, although listening to psychotherapists talk you could be forgiven for not believing it. Psychotherapists are a fractious bunch, given to arguing over fine points of theory and splitting into ever-smaller schools of thought. This ought not to surprise us. Psychotherapy is a very personal activity. You have to be fully engaged in it to do it well, so it is difficult to be dispassionate.

Throughout this book we describe how various therapies differ from one another, so that you can get a grasp of them. In truth they have much more in common. What can seem to be very diverse practices, using strikingly different languages, often draw on a common set of processes and lead to similar outcomes.

Psychoanalysis is no longer the commonest, nor indeed the dominant, psychotherapy, but it has a unique place in its history and development. Psychoanalytic principles and practices have influenced virtually all subsequent therapies. Getting a grasp of them will help you to understand what follows, so we will describe them in considerable detail. Let us begin with the remarkable man who started it all.

Sigmund Freud (1856–1939)

Sigmund Freud was born in Freiberg, in what is now the Czech Republic, to a Jewish wool merchant and his much younger third wife who doted on her son. From the age of nine he lived in Vienna, at that time the liberal and cosmopolitan capital of the Austro-Hungarian Empire. The studious and talented Freud excelled at his schooling and became a doctor and subsequently a neurologist, carving out a promising career as a researcher.

He met his future wife, Martha Bernays, in 1882 and promptly became engaged. He needed to earn a decent salary to get married so he took a clinical post in the Vienna General Hospital. He managed to continue researching part time, and published on the properties of cocaine and on some neurological disorders. All neurologists, then as now, are regularly confronted with the puzzle of whether a patient’s symptoms result from nerve damage or from underlying psychological problems. Neuroses, especially hysterical disorders as they were called then, produced a range of apparently inexplicable and disabling physical symptoms such as paralyses, weaknesses, pains, and fits.

Married in 1886, Freud established a private practice specializing in neurotic patients, many with these hysterical disorders. He lived and worked in the same spacious apartment for forty-seven years until he was driven out by the Nazis in 1938. By that time he was a very sick man and died in London a year later. A very domestic individual, Freud was sober and predictable in his habits, invariably dressed in a tweed suit. His only obvious vice was smoking cigars, which eventually caused his fatal cancer of the mouth. He was inordinately proud of his six children, particularly his youngest daughter Anna, who became a noted child analyst.

In 1885–6 Freud spent four months visiting the world renowned Jean-Martin Charcot in Paris. Charcot specialized in distinguishing hysterical from epileptic fits and used hypnosis to induce and control the seizures. Freud was very impressed, and on his return to Vienna began to use hypnosis in his practice.

Psychoanalysis begins to take form

Freud’s use of hypnosis continued for some years. He would put his patient into a light trance and, placing his hands on their temples, suggest that their symptoms were becoming weaker or that power was slowly returning to a paralysed limb. However, in 1896, along with Joseph Breuer, he published five detailed case histories, Studies in Hysteria. In these they used hypnosis not so much to cure the disorder but to gain an understanding of it, to reveal the underlying neurotic conflicts.

Freud’s attention had moved from removing symptoms to trying to understand the causes behind them. This preoccupation was never to leave him, and it has remained central to most psychotherapy practice. Freud was not the first to recognize the role of the unconscious in neuroses, but he stands out because of his total commitment to identifying the causes of the symptoms. He was committed to honesty and insisted on sharing the unvarnished truth with his patients. Psychoanalysis aimed to explore unconscious mental processes. What were its tools?

Free association and dream interpretation

Abandoning hypnosis, Freud began to encourage his patients to relax and say whatever came into their minds. To help them relax they lay on a couch, and he sat just out of view (see ). Uncomfortable or disturbing thoughts and feelings—which had been actively suppressed in the unconscious mind—could then bubble up, evading the usual controls. He called this process free association. A similar process occurs during sleep when repressed thoughts make their way into consciousness, albeit exotically disguised in dreams.

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3. Freud’s consulting room around 1910. Patients would have no chance of being unaware of Freud’s personality and interests when lying in this room

Freud called what we remember on waking the dream’s manifest content. The dream’s real meaning, its unconscious latent content, has been distorted in its journey to consciousness by several recognizable processes. These include condensation when a single image serves to convey a number of different concerns, or symbolization when a vivid image stands for an unacceptable preoccupation. One rather hackneyed example is dreams of trains being understood to symbolize sexual intercourse. Analysis was needed to uncover the latent content.

Searching out the clues to neurosis revealed in dreams and free associations remained the basis of all Freud’s subsequent work. He believed that nothing was ever truly forgotten, and that nothing was ever just coincidence, hence the ‘Freudian slip’. Everything had a meaning, and that meaning could be uncovered by analysis. Over his lifetime Freud radically changed many of his ideas about mental mechanisms, the origins of neurotic symptoms, as well as practical aspects of psychoanalysis. However, he never deviated from his search to understand and uncover unconscious conflicts.

The most distinctive feature of psychoanalysis is the interpretation. An interpretation is when the analyst helps make the link between unconscious meaning and motivation, conscious experience, and behaviour. Clarifying these links promotes insight into the previously obscure origins of current difficulties. The patient can then respond more rationally to issues in her life.

Infantile sexuality

Freud initially believed that the hysterical disorders in his women patients were the result of sexual abuse in childhood, often by their fathers. Over time he came to doubt this explanation. He concluded that these stories of abuse arose from fantasies, from the child’s desire for an intense, intimate relationship with her father. To explain this he proposed that right from birth we have strong instinctual (sexual) drives, which he called the libido.

Freud proposed that the libido developed through several stages culminating in the Oedipus complex. Around the age of three to five years the child struggles to have an exclusive and intense relationship with the parent of the opposite sex and experiences the other parent as a rival. This rivalry and jealousy generates the Oedipal triangle.

Freud believed that it was possible to become stuck at any of several earlier developmental stages, and that this would prevent healthy maturation. He saw the successful resolution of the Oedipal triangle as essential for mature sexuality. This was necessary for forming realistic and affectionate adult relationships, and to tolerate sharing. Those who did not resolve it were trapped into seeking unrealistic, exclusive, and oversexualized relationships.

Mental structures: the ego, id, and super-ego

Freud became interested in the mental structures that shaped and modified these strong instinctual drives. He believed they arose in the primitive and chaotic unconscious mind—what he called the id (‘it’ in Latin). They both influenced and were controlled by the more rational conscious mind, the ego (‘I’ in Latin). Freud proposed a third structure, the super-ego, for our self-critical and controlling behaviour—our conscience.

He initially thought the super-ego was derived from our parents. However, the scathing self-criticism he observed in severely depressed patients made him question its rationality. His solution was to conclude that while it was derived from the ego (representations of our parents and upbringing), it was powered by the id, which contributed its primitive intensity. Many analysts (such as Melanie Klein) now believe that this intensity is because the Oedipal conflict actually takes place much earlier. Consequently, the super-ego acquires some of the characteristics of the fearsome monster of a small child’s nightmares, rather than just an overly strict parent.

Freud’s final addition to mental structures was the concept of defence mechanisms. These are our mental mechanisms to deal with unwelcome unconscious thoughts and feelings on a day-by-day basis. Unlike the repression in neurosis, these do not require constant energy to hold the threatening thoughts and feelings out of consciousness. Defence mechanisms become stable parts of the personality—reliable, automatic ways of dealing with uncomfortable issues as they arise. Defences include denial (as in the alcoholic who bluntly insists he has no problem), projection (where an angry person claims he is ‘just fine’ but everyone around them is furious), and splitting (which deals with complex relationships by making one person the good guy and the other the villain).

Exploring defence mechanisms became an important part of psychoanalysis. Initially they were seen simply as a resistance to analysis, which had to be overcome to get to the underlying conflicts. They later came to be seen as key features of a patient’s character whose understanding was helpful in its own right.

A particular aspect of treatment that troubled Freud was when patients idealized him, especially when they declared they had fallen in love with him. He called this transference, believing it was the transfer of emotions from previous important relationships on to the current therapeutic one. He initially saw it simply as resistance, but over time came to believe it is an essential part of treatment—a vital route into the unconscious.

Transference analysis is now a central feature of all psychoanalysis. It uses the patient’s responses to the therapist as a guide to how they experience their other relationships and themselves. It also includes analysing counter-transference, the feelings evoked in the therapist by the patient. Interpretations which link the transference relationship with the patient’s life situation and simultaneously with important past experiences are considered to be the most potent. Counter-transference work enables psychoanalysts (and psychoanalytic therapists) to work with adults who are less verbal, or even young children seen with their parents.

The spread of psychoanalysis

All the early analysts in Vienna were Jewish (Carl Jung in Switzerland was the first non-Jewish practitioner). The rise of Nazism in the 1930s forced them to leave for the US, the UK, and South America, where they established many psychoanalytic institutes. Theories developed and disagreements lead to splits. The most acrimonious was the early departure of Carl Jung, whose thinking (see ) had always incorporated spiritual dimensions. This grated with Freud’s more reductionist emphasis on the role of sexuality. Numerous other ‘schools’ of psychoanalysis have developed, many long-since faded away.

In the US the ‘neo-Freudians’ and ‘ego-psychologists’ established a strong presence, with figures such as Karen Horney, Erich Fromm, Alfred Adler, and Harry Stack Sullivan. They proposed a broader understanding of the origins of neuroses, emphasizing the role of culture and social influences. In the UK Melanie Klein’s approach effectively bypassed the ego to interpret primitive emotions and fantasies right from the start. She was also one of the first to use psychoanalysis with children.

More recently, the French psychoanalyst and philosopher Jacques Lacan has profoundly influenced psychoanalysis in much of continental Europe and Latin America. A prodigious intellectual, Lacan’s writings are incredibly difficult to understand and some of his practice eccentric. For instance, his analytical ‘hour’ always started late and lasted only as long as he thought it useful or productive.

Psychoanalytic training

Psychoanalysis is very strict about who can call themselves analysts and about what training and supervision is required. In the 1920s Carl Jung insisted that analysts should have their own training analysis. Nowadays the training is demanding, involving several years of training analysis, attendance at seminars, and close supervision of early treatments. This protracted and expensive training is thought by some to make analysis too rigid and inhibit originality. It certainly makes analysis expensive.

Being in analysis: once a week or every day?

Few analysts see all their patients five days a week. It is neither affordable nor compatible with modern lives. Most patients have one or two sessions a week. Some analysts consider this an unavoidable compromise, and that difficult patients still need a ‘full analysis’. The majority have adapted to less frequent sessions and consider the advantages to probably outweigh the disadvantages. The experience may not be so intense, but it focuses the minds of both partners and allows time to reflect and reality-test between sessions.

Some time ago we both shared a flat in south London with a trainee analyst. He headed off before seven in the morning to Hampstead, five mornings a week, for his analysis. He then came back to his full-time job as a psychiatrist, before returning to Hampstead to his patients or seminars every evening, to come home exhausted at nine or ten at night. We often joked with him that he could not have anything to speak about in his sessions other than the analysis itself and the traffic jams between us and Hampstead! His experience was that this very intensity allowed him to delve deeper into personal understanding without daily life intruding too much. This ‘time out’ from normal life, inhabiting a different mental zone, is undoubtedly a special quality of a full analysis. But what should one expect from weekly analytic treatment, often called psychoanalytic or psychodynamic psychotherapy?

The first sessions

The first session will be devoted to finding out why you have come. The therapist will introduce herself and explain that she is there to listen to you. She will work with you to help you understand your problems better, so that you can find solutions to them. She will usually outline how the process works and give you some idea of what to expect. Sessions are likely to last an analytic hour (50 minutes) and to be at a regular time each week. The 50-minute hour gives the therapist time between patients to write notes and ensures that each session starts on time.

Analytic therapies use punctuality and regularity to provide a sense of structure and security around what can be an emotionally harrowing process. Regularly coming late or missing sessions will be seen as evidence of resistance—that you are trying to avoid painful issues. Analytic psychotherapists are strict with all routines and boundaries and rarely permit contact between sessions. Even if you are very upset at the end of a session you will be encouraged to contain your emotions until the next one. Living with, and trying to understand, powerful feelings is part of the treatment.

Most therapists will offer a small number of exploratory sessions before you both decide whether or not to continue. Your therapist is likely to be relatively silent, but that does not mean that she is not listening. Everything said in the room is confidential. Confronting painful issues can temporarily increase distress rather than reducing it, and it is important to stay engaged. That the analyst does not rush to comfort you does not mean at all that she is indifferent, but rather that she wants you to have time to better understand what is going on. All that is expected of you is to try and be as honest as possible.

Having outlined the process the therapist will encourage you to talk about your problems. ‘Tell me in your own words what is going on in your life and why you are here. Just describe it, don’t try to explain it, and take your time.’ Many people find this first session highly emotional, often bringing an enormous sense of release, with words and emotions flooding out. The therapist will not interrupt much in the first session. This is not a time for detailed clarification but for getting an overview; your emotions are as much a part of this as your story.

Therapists usually take care to wind up the first session in good time. This allows them to summarize and discuss with you any thoughts they have about what you have said, for example:

The relationship you describe with your partner seems to be burdened with anger, possibly carried over from your disappointment with your father. You have shown me how upsetting it remains for you, and that probably needs to be better understood. We will need to continue with this next time.

This reviewing also allows time for you to move back out of the emotionally intense world of psychotherapy and prepare to face the everyday world as you step outside. Do not be surprised though, if you do not get any clever summary or psychological ‘diagnosis’. Many therapies have identified assessment sessions, but analytic therapy has a much more open-ended approach to how long treatment will last and what will be worked on.

Free association, interpretation, and working through

In psychoanalytic therapy you will remain very much in the driving seat. The therapist will not tell you what you should or should not talk about. Free association (saying whatever comes into your mind) is still the cornerstone of the treatment. This is matched by the analyst’s free-floating attention to themes that emerge in what you choose to talk about. You are nowadays more likely to sit in a chair and face your therapist than lie on a couch. You will also be encouraged to report and discuss your dreams.

Analysts believe nothing you say is random. It is all important and it stems from the preoccupations that are troubling you, but which you may be trying to avoid. The meaning will become clear in time, as long as you are patient and do not rush it. This sounds self-indulgent and easy but it is not. Most of us can find the apparent lack of structure very stressful initially, and want the therapist to be more directive. Very often in the beginning we experience our mind as being totally blank. The analyst may reply that it is almost impossible ‘not to think’, we should just take time, and the thoughts will surface.

Analytic psychotherapy is based on the premise that if we understand what is going on in our minds, then we have the possibility to change it—in Freud’s words, ‘where id was, ego shall be’. So analysis aims above all else for self-understanding, for insight. Over time the therapist will increasingly make interpretations to promote insights. Imagine describing the surprising anger you felt when your partner forgot your birthday:

It was ridiculous. I know he has been very busy, and I know he loves me, but when he sat there chattering away and clearly had completely forgotten I felt hate, real hate. I wanted to scream at him or pack my bags and leave. Yet he is considerate and affectionate and I knew perfectly well he had been preoccupied with the house repairs. How could I feel such hate over something so trivial?

The therapist might link this to your earlier descriptions of a sense of neglect when you were growing up:

This sounds very similar to how you described feeling left out and ignored by your father when your sister was ill. How hurtful it felt, yet because of the worry about your sister you could not have a tantrum or tell your dad. Could there be a link with that pain and not just the forgotten birthday?

Interpretations help us recognize how our responses (whether thoughts, feelings, or actions) are so damaging or distressing. This is because they relate not just to what is happening now but also to earlier, unresolved, and formative experiences. They are rarely blinding flashes of insight that instantly clear away the fog of neurosis. They have to be repeated, building up a richer understanding of what are well-entrenched, complex patterns of thought and behaviour. The most effective interpretations are believed to be those that illuminate the similarities between important past relationships and current experiences in both your day-to-day life and in what is going on in the analysis itself—the transference. Such triangular interpretations (see ) are sometimes called mutative interpretations because of their power to stimulate change.

Using such links there is the possibility of working through the pain of past experiences—coming to terms with them and moving on. Working through is the main task of therapy; more time-consuming and less glamorous than the interpretations, but essential for personal growth and healing. In working through, the transference relationship to the analyst assumes a central role. Old feelings of anger, despair, rejection, or resentment that have festered under the surface for decades are reignited and experienced in the room. The analyst is the object of these feelings and must withstand them, neither retaliating or wilting under their attack, nor rushing to remove discomfort.

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4. Triangle of persons

The concerned but relatively reserved manner that analysts adopt, the blank screen, makes it possible to project transferred emotions on to them. However, they should be blank but not absent—without trust and a sense of security in the relationship such projection would be altogether too frightening to engage in. The relationship must have enough depth for these storms to be both weathered and confronted while new patterns are evolved. Working through enables us to make the hugely important shift from understanding the problem intellectually (‘I see that this has upset me because I tend to believe that nobody is capable of helping me’) to really feeling it (‘I really did feel unloved and unsupported—yet now I sense that people in my life can help me’).

Analysis of defences

Latterly, analytic therapists have focused more on helping us understand our habitual defence mechanisms—the patterns we regularly use to deal with things that would otherwise make us uncomfortable. So rather than going straight for the troubling conflicts underlying our neurotic problems, they may examine our routine ways of dealing with these uncomfortable issues. The two are not mutually exclusive and most therapists will do both. Sometimes work on defence mechanisms is needed in order to get to the underlying conflicts. A patient may, for instance, routinely intellectualize their problems, denying the emotional impact of them:

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5. Triangle of conflict

I realize that he has been too busy to remember my birthday; he’s been altogether far too busy. I just got a bit irritated because I worry he is not looking after himself enough and allowing time for himself.

Several sessions may be needed to understand the origins of this intellectual defence and the underlying conflict or feelings (see ).

When is enough? The ending of therapy

Traditional psychoanalysis can go on for years. There is no fixed limit—you carry on until the work is finished. Woody Allen once quipped after seeing his analyst for fifteen years, ‘I’ll give it one more year and then I’ll go to Lourdes’. Most analytic therapy nowadays is time-limited, although not a rigidly fixed number of sessions.

The analyst David Malan, who inspired the triangles used in and , pioneered a sharply focused thirty-session analysis, sometimes referred to as ‘short-term psychodynamic psychotherapy’. However, it is more likely that at the start you and the therapist will agree to see each other for a defined period, say once a week for twelve months, and then review.

Having an end in sight right from the beginning focuses the mind and avoids coasting along with no sense of urgency. Too much urgency, however, would inhibit the free-floating exploration essential to psychoanalytic work, so a balance has to be struck. A year seems a long time at the start, although it may not feel like that as the time approaches. The ending of therapy is often experienced as its most productive period.

Ending can be painful, even if the therapy has done its work—perhaps especially if it has. Strong feelings about the therapist are common, often of an idealizing nature, as they have been experienced as understanding and tolerant. The goal in analysis is to end with a balanced view of the therapist—neither all-knowing and wise, nor cold and insensitive. Achieving such a neutral appraisal while continuing to separate is difficult, so a ‘wobble’ is common towards the end. The gains may seem to be lost and symptoms may suddenly recur. This is a sign that the work of ending is underway, not a reason to delay it or to prolong therapy.

Who benefits most from psychoanalytic psychotherapy?

Those who go into analysis or psychoanalytic psychotherapy, particularly in private practice, are a highly self-selected group. This is a form of therapy that appeals broadly to those who are interested in the life of the mind or their internal world for its own sake. They may want increased self-understanding almost as much as they want relief from symptoms. It would be wrong to believe that you have to be some sort of intellectual to benefit, but the therapy is challenging and does require intellectual curiosity. It is best suited to those with difficulties in relationships in general rather than one relationship in particular, or with a gnawing dissatisfaction with their lives rather than isolated anxiety attacks. Psychoanalytic psychotherapy is certainly no quick fix. It is not for the impatient, but it can undoubtedly turn lives around when it works.

Previous: Chapter 1: What is psychotherapy and who is it for?
Next: Chapter 3: Post-Freudians: moving towards the interpersonal