Psychoanalysis In Clinical Psychology Research Paper

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1. Historical Background To Psychoanalysis

As is well known, Freud’s discovery of the talking cure was really that of an intelligent patient (Anna O) and her physician (Breuer). The patient found out for herself that certain symptoms disappeared when she succeeded in linking up fragments of what she said and did in an altered state of consciousness (which we would now call dissociative) with forgotten impressions from her waking life. Breuer’s remarkable contribution was that he had faith in the reality of the memories which emerged and did not dismiss the patient’s associations as products of a deranged mind. Breuer, of course, left the therapeutic battleﬁeld as soon as his patient’s speech and behaviors started to go beyond the boundaries marked out by turn-of-the-century Viennese society.

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Psychotherapy had to wait for a more powerful intellect who would not take fright at the instinctual elements in the psychological world of so-called civilized man. At ﬁrst Freud sought to unearth the traumas which he believed lay at the origins of the neuroses. Later, when confronted by evidently incorrect statements, he modiﬁed his theory assuming consistency between recollection and childhood psychic reality rather than physical reality. The issue of accuracy of memories of childhood sexual trauma remains controversial, although its relevance to psychoanalytic technique is at best tangential. Freud’s technique, however, was dramatically modiﬁed by his discoveries. The intense emotional relationship between patient and physician, which had its roots in catharsis following hypnotic suggestion, had gradually subsided into what was principally an intellectual exercise to reconstruct the repressed causes of psychiatric disturbance from the fragments of material derived from the patient’s associations. It was a highly mechanistic approach reminiscent of a complex crossword puzzle. In the light of therapeutic failures, however, Freud once more restored the emotional charge into the patient–physician relationship. However, in place of hypnosis and suggestion, he used the patient’s emotional reactions to the therapist. He thought that these reactions were explicable as transferences of the patients’ feelings about their past relationships on to the current analytic relationship. Instead of seeing the patient’s intense emotional reaction to the therapist as an interference, Freud came to recognize the importance of transference as a representation of earlier relationship experiences which could make the reconstruction of those experiences in analysis highly meaningful to that individual. Freud’s early clinical work lacked some of the rigor which came to characterize classical psychoanalysis. His occasional encouragement to his patients to join him on holiday might now be considered boundary violations. What is perhaps less well known is that Freud remained somewhat skeptical about the eﬀectiveness of psychoanalysis as a method of treatment. Indeed, autobiographies of some of his patients testify to his great ﬂexibility as a clinician and use of nonpsychoanalytic techniques, including behavioral methods. Nor was Freud the only clinician to use psychoanalytic ideas ﬂexibly. The Hungarian analyst Sandor Ferenczi was one of the ﬁrst to discover the treatment of phobic disorders by relaxation and exposure, although his discovery had little impact on subsequent clinical practice.

The technique of psychoanalysis after Freud’s death came to be codiﬁed with those (such as Alexander and French, and Frieda Fromm-Reichmann) who attempted to revive or retain Freud’s original clinical ﬂexibility being subjected to powerful intellectual rebuttals. In reality, psychoanalysts probably continued to vary in the extent to which they observed the ideals of therapeutic neutrality, abstinence, and a primarily interpretive stance, but these deviations could no longer be exposed to public scrutiny for fear of colleagues’ forceful condemnation. Personal accounts of analyses with leading ﬁgures yield fascinating insights into variations in technique, principally in terms of the extent to which the analyst made use of personal relationship. There has been an ongoing dialectic throughout the history of psychodynamic approaches between those who emphasize interpretation and insight and those who stress the unique emotional relationship between patient and therapist as the primary vehicle of change. The controversy dates back to disputes concerning the work of Ferenczi and Rank but re-emerged with the ﬁrst papers of Balint and Winnicott in London opposing a Freudian and Kleinian tradition, and somewhat later in the United States with Kohut opposing classical ego psychology.

Since the early 1990s, the pluralistic approach of modern psychoanalysis has brought out into the open many important dimensions along which psychoanalysts’ techniques may vary. In particular, the recent trend to consider analyst and patient as equal partners engaged in a mutual exploration of meaning has directly challenged many of the classical constructs. This controversy is too fresh to permit a conclusive assessment. It is evident, however, that fairly fundamental reconsideration of the aims and techniques of psychoanalytic therapy is currently underway.

2. The Basic Assumptions Of Psychoanalysis

Notwithstanding the theoretical heterogeneity of psychoanalytically based therapeutic approaches, there is probably a core set of assumptions to which all psychodynamic therapists would, to a greater or lesser extent, subscribe. These can be basically summarized as follows: (a) intrapsychic conﬂict is an all-pervasive aspect of human experience; (b) the mind is organized to avoid displeasure arising out of conﬂict and maximize the subjective sense of safety; (c) defensive strategies are adopted to manipulate ideas and experience in order to minimize displeasure; (d) psychological disturbance arises developmentally, so an adaptation that was rational and reasonable at an earlier developmental phase may leave residues that cause maladjustment in adulthood; (e) social experience is organized into relationship representations; self and other are depicted in speciﬁc interactions charged by powerful emotional content; (f ) these relationship representations inevitably re-emerge in the course of psychoanalytic treatment.

2.1 Technique—Principal Features

2.1.1 Neutrality And Abstinence. Based on the classical framework of libidinal theory, Freud explicitly enjoined against the analyst giving in to the temptation of gratifying the patient’s sexual desire. Obviously, this is primarily an ethical issue. However, within the psychoanalytic context it also justiﬁes the analyst’s stance of resisting the patient’s curiosity or using the therapeutic relationship in any way that consciously or unconsciously could be seen as motivated by the need to gratify their own hidden desires. Within this classical frame of reference, the patient must also agree to forgo signiﬁcant life changes where these could be seen as relevant to current psychotherapeutic work. In practice, such abstinence on the part of the patient is rare. Yet long-term psychodynamic treatment may founder if the emotional experiences of the therapy are obscured by the upheavals of signiﬁcant life events.

Abstinence primarily ensures the neutrality of the therapist. The therapist must resist the temptation to direct the patient’s associations and must remain neutral irrespective of the subject matter of the patient’s experiences or fantasies. It is perhaps this aspect of the psychoanalyst’s therapeutic stance that makes psychoanalysts most vulnerable to ridicule, but it is probably genuinely critical for the therapist to retain emotional distance from the patient to a degree which enables the latter to bring fantasies and fears of which they feel uncertain. Nevertheless, neutrality at its worst denies the possibility of sensitivity; recent literature on the process and outcome of psychotherapy makes it clear that the therapist’s genuine concern for the patient must be manifest if signiﬁcant therapeutic change is to be achieved.

2.1.2 Mechanisms Of Defense. Classical psychoanalytical theory and its modern equivalent (ego psychology) see conﬂict at the core of mental functioning. They see defenses as adaptations to intrapsychic conﬂict. Within object relations theories, defenses are seen as helpful to the individual to maintain an authentic or ‘true’ self representation or a nuclear self. Attachment theory understands defenses as assisting in the maintenance of desirable relationships. The Klein–Bion model makes limited use of the notion of defense mechanisms but uses the term in the context of more complex hypothetical structures called defensive organizations. The term underscores the relative inﬂexibility of some defensive structures which are thus best conceived of as personality types. For example, narcissistic personality disorder combines idealization and destructiveness; genuine love and truth are devalued. Such a personality type may have been protective to the individual at an earlier developmental stage, and has now acquired a stability or autonomy which must be rooted in the emotional gratiﬁcation which such a self-limiting form of adaptation provides.

Irrespective of the theoretical frame of reference, from a therapeutic viewpoint clinicians tend to diﬀerentiate between so-called primitive and mature defenses based on the cognitive complexity entailed in their functioning. In clinical work, primitive defenses are often noted together in the same individual. For example, individuals loosely considered ‘borderline’ tend to idealize and then derogate the therapist. They maintain their self-esteem by using splitting (clear separation of good from bad self-perception) and then projection. Projective identiﬁcation is an elaboration of the process of projection. An individual may ascribe an undesirable mental state to the other through projection but when the other can be unconsciously forced to accept the projection and experience its impact, the defense becomes far more powerful and stable. The analyst’s experience of a fragment of the patient’s self state has in recent years been considered an essential part of therapeutic understanding.

Through projective identiﬁcation the patient can experience a primitive mode of control over the therapist, whether in fantasy or in actualized form. Bion argued that when the self is experienced as being within another person (the therapist), the patient frequently attempts to exert total control over the recipient of the projection as part of an attempt to control split-oﬀ aspects of the self. Bion also argued that not all such externalizations were of ‘bad’ parts of the self. Desirable aspects of the self may also be projected, and thus projective identiﬁcation can be seen as a primitive mode of communication in infancy. There are other aspects of projective identiﬁcation which we commonly encounter clinically. These include the acquisition of the object’s attributes in fantasy, the protection of a valued aspect of the self from internal persecution through its evacuation into the object, and the avoidance or denial of separateness. It is thus a fundamental aspect of interpersonal relationships focused on unconscious fantasy and its appreciation is critical for the adequate practice of long-term psychotherapy.

Some mechanisms of defense are thought to be more characteristic of the less severe psychological disorders (e.g., depression, anxiety, obsessive– compulsive disorders, etc.). It is beyond the scope of this research paper to consider the various defense mechanisms in detail. Since Anna Freud’s classical work, these defense mechanisms have become fairly generally accepted, if only as terms of mild rebuke between mental health professionals. Thus we generally accept that motivated repression may be associated with momentary forgetting of conﬂictual contents, that denial may be invoked by individuals wishing to disavow the emotional signiﬁcance of an experience, that reaction formation is helpful in turning terror into aggression, and that identiﬁcation with the aggressor may be the only solution available to a maltreated child who becomes an abuser in adolescence.

The diagnostic signiﬁcance of defense mechanisms is controversial. Some researchers have claimed that an individual’s habitual mode of defense has predictive value beyond that of psychiatric diagnosis. Given the theoretical ambiguity that surrounds the concept, it is unlikely that its use as part of a diagnostic formulation is justiﬁed. It does, however, assist the psychoanalytic clinician in conceptualizing the patient’s reactions. In particular, these defenses are likely to be encountered in the course of psychoanalytic treatment at moments of intense emotional resistance. For example, it is common to observe patients experiencing considerable diﬃculty in recalling the contents of treatment sessions, yet their memory for other less central aspects of their lives appears to be exceptional. Being alert to the presence of defenses is important, not because it provides an opportunity for confrontation with ideas which the patient seems reluctant to acknowledge, but rather because it alerts the analyst to the presence of underlying anxieties which need to be tackled if resistance to the therapy is to be overcome.

2.1.3 Modes Of Therapeutic Action. The primary mode of the therapeutic action of psychoanalytic psychotherapy is considered to be insight. Insight may be deﬁned as the conscious recognition of the role of unconscious factors in current experience and behavior. Unconscious factors encompass unconscious feelings, experiences, and fantasies. Insight is more than mere intellectual knowledge. Thoma and Kachele (1987) consider insight to be equidistant from emotional experience and intellect. Etchegoyen (1991) distinguished descriptive insights from demonstrated (ostensive) insights which represent a more direct form of knowing, implying emotional contact with an event one has experienced previously.

Although speciﬁc formulations of the eﬀect of insight depend on the theoretical framework in which explanations are couched, there is general agreement that insight’s therapeutic eﬀect is to integrate mental structures in some way ( Thoma and Kachele 1987). Kleinian theorists see the healing of defensively created splits in the patient’s representation of self and others as crucial. One may be more speciﬁc by specifying split or part-objects as isolated representations of intentional beings whose motivation is insuﬃciently well understood for these to be seen as coherent beings. In this case insight could be seen as a development of the capacity to understand internal and external objects in mental state terms, thus lending them coherence and consistency. The same phenomenon may be described as an increasing willingness on the part of the patient to see the interpersonal world from a third-person perspective.

A simple demonstration to the patient of such an integrated picture of self or others is not thought to be suﬃcient. The patient needs to work through a newly arrived at integration. Working through is a process of both unlearning and learning: actively discarding prior misconceptions and assimilating learning to work with new constructions. The technique of working through is not well described in the literature, yet it represents the critical advantage of long-term over short-term therapy. Working through should be systematic and much of the advantage of long-term treatment may be lost if the therapist does not follow through insights in a relatively consistent and coherent manner.

In contrast to the emphasis on insight and working through are those clinicians who, as we have seen, emphasize the relationship aspect of psychoanalytic therapy (Balint, Winnicott, Loewald, Mitchell, and many others). This aspect of psychoanalytic therapy was perhaps most eloquently described by Loewald when he wrote about the process of change as: ‘set in motion, not simply by the technical skill of the analyst but by the fact that the analyst makes himself available for the development of a new ‘‘object-relationship’’ between the patient and the analyst …’ (Loewald 1960 pp. 224–5). Sandler and Dreher (1996) have recently observed ‘while insight is aimed for, it is no longer regarded as an absolutely necessary requirement without which the analysis cannot proceed.’ There is general agreement that the past polarization of interpretation and insight on the one hand and bringing about change by presenting the patient with a new relationship on the other was unhelpful. It seems that patients require both and both may be required for either to be eﬀective.

It has been suggested that change in analysis will always be individualized according to the characteristics of the patient or the analyst. For example, Blatt (1992) suggested that patients who were ‘introjective’ ( preoccupied with establishing and maintaining a viable self-concept rather than establishing intimacy) were more responsive to interpretation and insight. By contrast, anaclitic patients (more concerned with issues of relatedness than of self-development) were more likely to beneﬁt from the quality of the therapeutic relationship than from interpretation.

2.2 Psychoanalysis In Clinical Psychology

While intensive long-term psychoanalysis is relatively rarely oﬀered nowadays as a therapy except to those engaged in psychotherapeutic training, long-term psychoanalytic psychotherapy, using the same principles but with session frequency at once or twice a week is perhaps the most common long-term treatment oﬀered for personality and emotional problems by clinical psychologists. Clinical psychology is increasingly concerned with the evidence base of the treatments that psychological therapists engage in. What hope is there in this era of empirically validated treatments, which prizes brief structured interventions, for a therapeutic approach which deﬁnes itself by freedom from constraint and preconception, and counts treatment length not in terms of number of sessions but in terms of years? Can psychoanalysis ever demonstrate its eﬀectiveness, let alone cost-eﬀectiveness?

There can be no excuse for the thin evidence base of psychoanalytic treatment. In the same breath that psychoanalysts often claim to be at the intellectual origin of other talking cures (e.g., systemic therapy, cognitive behavior therapy), they also seek shelter behind the relative immaturity of the discipline to explain the absence of evidence for its eﬃcacy. Yet the evidence base of these ‘derivatives’ of psychoanalytic therapy has been far more ﬁrmly established than evidence for psychoanalysis itself. Of course, there are reasons given for this—reasons such as the long-term nature of the therapy, the complexity of its procedures, the elusiveness of its self-declared outcome goals, and the incompatibility of direct observation with the need for absolute conﬁdentiality. None of these reasons stands up to careful scrutiny, however.

What is surprising, given this unpropitious backdrop is that there is in fact some suggestive evidence for the eﬀectiveness of psychoanalysis as a treatment for psychological disorder.

2.2.1 The Evidence Base Of Psychoanalytic Treatment. Psychoanalysts have been encouraged by the body of research which supports brief dynamic psychotherapy. A meta-analysis of 26 such studies has yielded eﬀect sizes comparable to other approaches (Anderson and Lambert 1995). It may even be slightly superior to some other therapies if long-term follow-up is included in the design. One of the best-designed Randomized Controlled Trials (RCTs), the Sheﬃeld Psychotherapy Project (Shapiro et al. 1995), found evidence for the eﬀectiveness of a 16-session psychodynamic treatment based on Hobson’s (1985) model in the treatment of major depression. There is evidence for the eﬀectiveness of psychodynamic therapy as an adjunct to drug dependence programs ( Woody et al. 1995). There is ongoing work on a brief psychodynamic treatment for panic disorder (Milrod et al. 1997). There is evidence for the use of brief psychodynamic approaches in work with older people ( Thompson et al. 1987). There are some excellent studies conﬁrming the cost-eﬀectiveness of psychoanalytic brief therapy in a naturalistic clinical setting.

There are psychotherapy process studies which oﬀer qualiﬁed support for the psychoanalytic case. For example, psychoanalytic interpretations given to clients which are judged to be accurate are reportedly associated with relatively good outcome (CritsChristoph et al. 1988). There is even tentative evidence from the reanalysis of therapy tapes from the NIMH (National Institutes of Mental Health) Treatment of Depression Collaborative Research Program that the more the process of a brief therapy (CBT, cognitive behavior therapy, IPT, Interpersonal therapy) resembles that of a psychodynamic approach, the more likely it is to be eﬀective.

Evidence is available to support therapeutic interventions which are clear derivatives of psychoanalysis. However, most analysts would consider that the aims and methods of short-term, once-a-week psychotherapy are not comparable to ‘full analysis.’ What do we know about the value of intensive and long-term psychodynamic treatment? Here the evidence base becomes somewhat patchy.

The Boston Psychotherapy Study (Stanton et al. 1984) compared long-term psychoanalytic therapy (two or more times a week) with supportive therapy for clients with schizophrenia in a randomized controlled design. There were some treatment-speciﬁc outcomes, but on the whole clients who received psychoanalytic therapy fared no better than those who received supportive treatment. In a more recent randomized controlled study (Bateman and Fonagy 1999), individuals with a diagnosis of borderline personality disorder (BPD) were assigned to a psycho- analytically oriented day hospital treatment or treatment as usual. The psychoanalytic arm of the treatment included therapy groups three times a week as well as individual therapy once or twice a week over an 18-month period. There were considerable gains in this group relative to the controls and these diﬀerences were not only maintained in the 18 months following discharge but increased, even though the day hospital group received less treatment than the control group. A further controlled trial of intensive psychoanalytic treatment of children with chronically poorly con- trolled diabetes reported signiﬁcant gains in diabetic control in the treated group which was maintained at one-year follow-up (Moran et al. 1991). Experimental single case studies carried out with the same population supported the causal relationship between interpretive work and improvement in diabetic control and physical growth (Fonagy and Moran 1991). The work of Chris Heinicke also suggests that four-or ﬁve-times-weekly sessions may generate more marked improvements in children with speciﬁc learning diﬃculties than a less intensive psychoanalytic intervention (Heinicke and Ramsey-Klee 1986).

One of the most interesting studies to emerge recently was the Stockholm Outcome of Psycho- therapy and Psychoanalysis Project (Sandell 1999). The study followed 756 persons who received national insurance funded treatment for up to three years in psychoanalysis or in psychoanalytic psychotherapy. The groups were matched on many clinical variables. Four or ﬁve-times-weekly analysis had similar outcomes at termination when compared with one to two sessions per week psychotherapy. However, in measurements of symptomatic outcome using the SCL-90, improvement on three-year follow-up was substantially greater for individuals who received psychoanalysis than those in psychoanalytic psychotherapy. In fact, during the follow-up period, psychotherapy patients did not change but those who had had psychoanalysis continued to improve, almost to a point where their scores were indistinguishable from those obtained from a nonclinical Swedish sample.

Another large pre–post study of psychoanalytic treatments has examined the clinical records of 763 children who were evaluated and treated at the Anna Freud Centre, under the close supervision of Freud’s daughter (Fonagy and Target 1996). Children with certain disorders (e.g., depression, autism, conduct disorder) appeared to beneﬁt only marginally from psychoanalysis or psychoanalytic psychotherapy. Interestingly, children with severe emotional disorders (three or more axis I diagnoses) did surprisingly well in psychoanalysis, although they did poorly in once or twice a week psychoanalytic psychotherapy. Younger children derived greatest beneﬁt from intensive treatment. Adolescents appeared not to beneﬁt from the increased frequency of sessions. The importance of the study is perhaps less in demonstrating that psychoanalysis is eﬀective, although some of the eﬀects on very severely disturbed children were quite remarkable, but more in identifying groups for whom the additional eﬀort involved in intensive treatment appeared not to be warranted.

The Research Committee of the International Psychoanalytic Association has recently prepared a comprehensive review of North American and European outcome studies of psychoanalytic treatment (Fonagy et al. 1999; also see http://www.ipa.org.uk). The committee concluded that existing studies failed to unequivocally demonstrate that psychoanalysis is eﬃcacious relative to either an alternative treatment or an active placebo, and identiﬁed a range of methodological and design problems in the 50 or so studies described in the report. Nevertheless, the report is encouraging to psychoanalysts. A number of studies testing psychoanalysis with ‘state of the art’ methodology are ongoing and are likely to produce more compelling evidence over the next years. Despite the limitations of the completed studies, evidence across a signiﬁcant number of pre–post investigations suggests that psychoanalysis appears to be consistently helpful to patients with milder (neurotic) disorders and somewhat less consistently so for other, more severe groups. Across a range of uncontrolled or poorly controlled cohort studies, mostly carried out in Europe, longer intensive treatments tended to have better outcomes than shorter, nonintensive treatments. The impact of psychoanalysis was apparent beyond symptomatology, in measures of work functioning and reductions in health care costs.

3. Conclusions

Psychoanalytic notions are no longer considered ‘outlandish’ from the point of view of empirical psychology. New discoveries from the experimental human sciences have yielded much data consistent with psychoanalytic ideas. None of these studies can ‘prove’ psychodynamic ideas as the two pertain to independent realms of human functioning: the lab- oratory and the consulting room. However, taken as a whole, they point to the existence of underlying psychological processes posited by psychodynamic theoreticians when oﬀering their model of human development and the pathological outcomes that may arise from it. Psychodynamic theory is unlikely ever to be comprehensively validated in empirical studies. All that we can hope for is that the general model of a person, painstakingly assembled on the basis of neuropsychological, social, and cognitive–psychological investigations, will not be too dissimilar from the vision of human functioning which has emerged from the clinical endeavors of psychodynamically oriented practitioners.

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