Current Status of Psychoanalysis Research Paper

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1. Freud’s Theory Of The Mental Apparatus

Freud’s (1953a) starting point was his study of hysterical patients and the discovery that, when he found a way to help these patients piece together a coherent account of the antecedents of their conversion symptoms, dissociative phenomena, and pathological affective dispositions, all these psychopathological phenomena could be traced to traumatic experiences in their past that had become unconscious. In the course of a few years Freud abandoned his early efforts to recover repressed material by means of hypnosis, and replaced hypnosis with the technique of ‘free association,’ an essential aspect of psychoanalytic technique until the present time.

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Practicing this method led Freud to several lines of discovery: to begin, he conceptualized unconscious mechanisms of defense that opposed the recovery of memories by free association. He described these mechanisms, namely repression, negation, isolation, projection, introjection, transformation into the opposite, rationalization, intellectualization, and most important, reaction formation. The latter involves overt, chronic patterns of thought and behavior that serve to disguise and disavow opposite tendencies linked to unconscious traumatic events and the intrapsychic conflicts derived from them. The discovery of reaction formations led Freud to the psychoanalytic study of character pathology and normal character formation, and still constitutes an important aspect of the contemporary psychoanalytic understanding and treatment of personality disorders (for practical purposes, character pathology and personality disorders are synonymous concepts).

A related line of development in Freud’s theories was the discovery of the differential characteristics of conscious and unconscious thinking. Freud differentiated conscious thinking, the ‘secondary process,’ invested by ‘attention cathexis’ and dominated by sensory perception and ordinary logic in relating to the psycho-social environment, from the ‘primary process’ of the ‘dynamic unconscious.’ That part of the unconscious mind he referred to as ‘dynamic’ exerted constant pressure or influence on conscious processes, against the active barrier constituted by the various defensive operations, particularly repression. The dynamic unconscious, Freud proposed, presented a general mobility of affective investments, and was ruled by the ‘pleasure principle’ in contrast to the ‘reality principle’ of consciousness. The ‘primary process’ thinking of the dynamic unconscious was characterized by the absence of the principle of contradiction and of ordinary logical thinking, the absence of negation and of the ordinary sense of time and space, the treatment of a part as if it were equivalent to the whole, and a general tendency toward condensation of thoughts and the displacement of affective investments from one to another mental content.

Finally, Freud proposed a ‘preconscious,’ an intermediate zone between the dynamic unconscious and consciousness. It represented the storehouse for retrievable memories and knowledge and for affective investments in general, and it was the seat of daydreaming, in which the reality principle of consciousness was loosened, and derivatives of the dynamic unconscious might emerge. Free association, in fact, primarily tapped the preconscious as well as the layer of unconscious defensive operations opposing the emergence of material from the dynamic unconscious. This model of the mind as a ‘place’ with unconscious, preconscious, and conscious ‘regions’ constituted Freud’s ‘topographic theory.’ He eventually replaced it with the ‘structural theory’ namely, the concept of three interacting psychic structures, the ego, the superego and the id (Freud 1961).

1.1 The Id

The id is the mental structure that contains the mental representatives of the ‘drives,’ that is, the ultimate intrapsychic motivations that Freud (1955) described in his final, ‘dual drive theory’ of libido and aggression, or metaphorically, the sexual or life drive and the destruction or death drive. In exploring unconscious mental processes, what at first appeared to be specific traumatic life experiences turned out to reflect surprisingly consistent, repetitive, intrapsychic experiences of a sexual and aggressive nature.

Freud (1953a) was particularly impressed by the regularity with which his patients reported the emergence of childhood memories reflecting seductive and traumatic sexual experiences on the one hand, and intense sexual desires and related guilt feelings, on the other. He discovered a continuity between the earliest wishes for dependency and being taken care of (the psychology, as he saw it, of the baby at the mother’s breast) during what he described as the ‘oral phase’ of development; the pleasure in exercising control and struggles around autonomy in the subsequent ‘anal phase’ of development, (the psychology of toilet training); and, particularly, the sexual desire toward the parent of the opposite gender and the ambivalent rivalry for that parent’s exclusive love with the parent of the same gender. He described this latter state as characteristic of the ‘infantile genital stage’ (from the third or fourth to the sixth year of life) and called its characteristic constellation of wishes and conflicts the positive Oedipus complex. He differentiated it from the negative Oedipus complex, that is, the love for the parent of the same gender, and the corresponding ambivalent rivalry with the parent of the other gender. Freud proposed that oedipal wishes came to dominate the infantile hierarchy of oral and anal wishes, becoming the fundamental unconscious realm of desire.

Powerful fears motivated the repression of awareness of infantile desire: the fear of loss of the object, and later of the loss of the object’s love was the basic fear of the oral phase, directed against libidinal wishes to possess the breast; the fear of destructive control and annihilation of the self or the object was the dominant fear of the anal phase directed against libidinal wishes of anal expulsion and retentiveness, and the fear of castration, ‘castration anxiety,’ the dominant fear of the oedipal phase of development, directed against libidinal desire of the oedipal object. Unconscious guilt was a dominant later fear, originating in the superego and generally directed against drive gratification (see Sect. 1.3). Unconscious guilt over sexual impulses unconsciously equated with oedipal desires constitutes a major source of many types of pathology, such as sexual inhibition and related character pathology.

Freud described the oral phase as essentially coinciding with the infantile stage of breast feeding, the anal phase as coinciding with struggles around sphincter control, and the oedipal stage as developing gradually during the second and through the fourth years, and culminating in the fourth and the fifth years of life. This latter phase would then be followed by more general repressive processes under the dominance of the installation of the superego, leading to a ‘latency phase’ roughly corresponding to the school years, and finally, to a transitory reactivation of all unconscious childhood conflicts under the dominance of oedipal issues during puberty and early adolescence.

The drives represent for human behavior what the instincts constitute for the animal kingdom, that is, the ultimate biological motivational system. The drives are constant, highly individualized, developmentally shaped motivational systems. Under the dominance of the drives and guided by the primary process, the id exerts an on-going pressure toward gratification, operating in accordance with the pleasure principle. Freud initially equated the drives with primitive affects. After discarding various other models of unconscious motivation, he ended up with the dual drive theory of libido and aggression.

He described the libido or the sexual drive as having an ‘origin’ in the erotogenic nature of the leading oral, anal, and genital bodily zones; an ‘impulse’ expressing the quantitative intensity of the drive by the intensity of the corresponding affects; an ‘aim’ reflected in the particular act of concrete gratification of the drive; and an ‘object’ consisting of displacements from the dominant parental objects of desire.

The introduction of the idea of an aggressive or ‘death’ drive, arrived at later in Freud’s writing, stemmed from his observations of the profound self-destructive urges particularly manifest in the psycho-pathology of major depression and suicide, and of the ‘repetition compulsion’ of impulse driven behavior that frequently seemed to run counter to the pleasure principle that supposedly governed unconscious drives. He never spelled out the details of the aggressive drive as to its origins. Freud described drives as intermediate between the body and the mind; the only thing we knew about them, Freud (1957a) suggested, were ‘representations and affects.’

1.2 The Ego

While the id is the seat of the unconscious drives, and functions according to the ‘primary process’ of the dynamic unconscious, the ego, Freud (1961) proposed, is the seat of consciousness as well as of unconscious defense mechanisms that, in the psychoanalytic treatment, appear as ‘resistance’ to free association. The ego functions according to the logical and reality based principles of ‘secondary process,’ negotiating the relations between internal and external reality. Guided by the reality principle, it exerts control over perception and motility; it draws on preconscious material, controls ‘attention cathexes,’ and permits motor delay as well as selection of imagery and perception. The ego is also the seat of basic affects, particularly anxiety, as an alarm signal against the danger of emergence of unconscious, repressed impulses. This alarm signal may turn into a disorganized state of panic when the ego is flooded with external perceptions that activate unconscious desire and conflicts, or with overwhelming, traumatic experiences in reality that resonate with such repressed unconscious conflicts, and overwhelm the particularly sensitized ego in the process.

Freud originally equated the ‘I,’ that is, the categorical self of the philosophers, with consciousness. Later, once he established the theory of the ego as an organization of both conscious and unconscious functions, he at times treated the ego as if it were the subjective self, and at other times, as an impersonal organization of functions. Out of this ambiguity evolved the contemporary concept of the self within modern ego psychology as well as in British and American object relations and cultural psychoanalytic contributions (Kernberg 1984). An alternative theory of the self was proposed by Kohut (1971), the originator of the self-psychology approach within contemporary psychoanalysis.

Nowadays, an integrated concept of the self as the seat of subjectivity is considered an essential structure of the ego, and the concept of ‘ego identity’ refers to the integration of the concept of the self. Because developmental processes in early infancy and childhood are now better understood, an integrated self concept usually goes hand in hand with the capacity for an integrated concept of significant others. An unconscious tendency toward primitive dissociation or ‘splitting’ of the self-concept and of the concepts of significant objects runs counter to such integration.

Character, from a psychoanalytic perspective, may be defined as constituting the behavioral aspects of ego identity (the self-concept) and the internal relations with significant others, (the internalized world of ‘object relations’). The sense of personal identity and of an internal world of object relations in turn reflects the subjective side of character. It was particularly the ego psychological approach—one of the dominant contemporary psychoanalytic schools—that developed the analysis of defensive operations of the ego, and of pathological character formation as a stable defensive organization that needed to be explored and resolved in the psychoanalytic treatment. In the process, ego psychology importantly contributed to the psychoanalytic treatment of personality disorders.

Freud (1957c) conceptualized narcissism as the libidinal investment of the ego or self, in contrast to the libidinal investment of significant others (‘objects’). In proposing the possibility of a withdrawal of libidinal investment from others with an excessive investment in the self as the basic feature of narcissistic pathology, he pointed to a broad spectrum of psychopathology, and thus first stimulated the contribution of Abraham (1919), and later those of Grunberger (1979), Jacobson (1964), Kernberg (1975), Klein (1957), Kohut (1971), and Rosenfeld (1964). Thus crystallized the description of the narcissistic personality as a disorder derived from a pathological integration of a grandiose self as a defense against unbearable aggressive conflicts, particularly around primitive envy.

1.3 The Superego

In his analysis of unconscious intrapsychic conflicts between drive and defense, Freud regularly encountered unconscious feelings of guilt in his patients, reflecting an extremely strict, unconscious infantile morality which he called the superego. This unconscious morality could lead to severe self-blame and self-attacks, and particularly to abnormal depressive reactions, which he came to regard as expressing the superego’s attacks on the ego. It was particularly in studying normal and pathological mourning, that Freud (1957c) arrived at the idea of excessive mourning and depression as reflecting the unconscious internalization of the representation of an ambivalently loved and hated lost object. In unconsciously identifying the self with that object introjected into the ego, the individual now attacked his own self in replacement of the previous unconscious hatred of the object; and the internalization of aspects of that object into the superego reinforced the strictness of the individual’s preexisting unconscious infantile morality.

Freud traced the origins of the superego to the overcoming of the Oedipus complex via unconscious identification with the parent of the same gender: in internalizing the oedipal parent’s prohibition against the rivalry with him or her and the unconscious death wishes regularly connected with such a rivalry, and against the incestuous desire for the parent of the other gender, this internalization crystallized an unconscious infantile morality. The superego, thus based upon prohibitions against incest and parricide, and a demand for submission to, and identification with the oedipal rival, became the guarantor of the capacity for identification with moral and ethical values in general.

Freud also described the internalization of the idealized representations of both parents into the superego in the form of the ‘ego ideal.’ He suggested that the earliest sources of self esteem, derived from mother’s love, gradually fixated by the baby’s and small child’s internalizations of the representations of the loving mother into the ego ideal, led to the parental demands also becoming internalized. In other words, normally self-esteem is maintained both by living up to the expectations of the internalized idealized parental objects, and by submitting to their internalized prohibitions. This consideration of self-esteem regulation leads to the clinical concept of narcissism as normal or pathological self-esteem regulation, in contrast to the theoretical concept of narcissism as the libidinal investment of the self.

2. Psychoanalytic Treatment

2.1 The Psychoanalytic Theory Of Psychopathology

This theory proposes that the clinical manifestations of the symptomatic neuroses, character pathology, perversions, sexual inhibitions, and selected types of psychosomatic and psychotic illness reflect unconscious intrapsychic conflicts between drive derivatives following the pleasure principle, defensive operations reflecting the reality principle, and the unconscious motivations of the superego. Unconscious conflicts between impulse and defense are expressed in the form of structured conflicts between the agencies of the tripartite structure. There are ego defenses against impulses of the id; the superego motivates inhibitions and restrictions in the ego; at times the repetitive, dissociated expression of id impulses (‘repetition compulsion’) constitutes an effective id defense against superego pressures. The resolution of unconscious conflicts implies the analysis of all these intersystemic conflicts.

All these conflicts are clinically expressed by three types of phenomena: (a) inhibitions of normal ego functions regarding sexuality, intimacy, social relations, and affect activation; (b) compromise formations between repressed impulses and the defenses directed against them; and (c) dissociative expression of impulse and defense. This latter category implies a dominance of the splitting mechanisms referred to before. These have acquired central importance in the understanding of severe character pathology as reflected in contemporary psychoanalytic thinking.

2.2 The Structural Formulation Of The Psychoanalytic Method

Psychoanalytic treatment consists, in essence, in facilitating the reactivation of the pathogenic unconscious conflicts in the treatment situation by means of a systematic analysis of the defensive operations directed against them. This leads to the gradual emergence of repressed impulses, with the possibility of elaborating them in relation to the analyst, and their eventual adaptive integration into the adult ego. Freud (1953c) had described the concept of ‘sublimation’ as an adaptive transformation of unconscious drives: drive derivatives, converted into a consciously tolerable form, are permitted gratification in a symbolic way while their origin remains unconscious. The result of this process is an adaptive, non-defensive compromise formation between impulse and defense. In analysis, the gradual integration into the patient’s conscious ego of unconscious wishes and desires from the past and the understanding of the phantasied threats and dangers connected with them facilitates their gradual elaboration and sublimatory expression both in the consulting room and in everyday life.

2.3 The Object Relations Theory Formulation Of Psychoanalytic Treatment

In the light of contemporary object relations theory, the formulation based upon the structural theory (resolution of unconscious conflicts between impulse and defense) has changed, in the sense that all unconscious conflicts are considered to be imbedded in unconscious internalized object relations. Such internalized object relations determine both the nature of the defensive operations and of the impulses against which they are directed. These internalized object relations constitute, at the same time, the ‘building blocks’ of the tripartite structure of id, ego, and superego. Object relations theory proposes that the gradual analysis of intersystemic conflicts between impulse and defense (structured into conflicts between ego, superego, and id, decomposes the tripartite structure into the constituent conflicting internalized object relations. These object relations are reactivated in the treatment situation in the form of an unconscious relation between self and significant others replicated in the relation between patient and analyst, that is, the ‘transference.’

The transference is the unconscious repetition in the ‘here and now’ of unconscious, conflicting pathogenic relationships from the past. The transference reflects the reactivation of the past conflict not in the form of a memory, but in the form of a repetition. This repetition provides essential information about the past, but constitutes at the same time, a defense in the sense that the patient repeats instead of remembering. Therefore, transference has important informative features that need to be facilitated in their development, and defensive features that need to be therapeutically resolved once their nature has been clarified. Transference analysis is the fundamental ingredient of the psychoanalytic treatment.

2.4 The Psychoanalytic Treatment Process

Gill (1954) in a classical definition that is still relevant today, proposed the definition of psychoanalysis as a treatment that facilitates the development of a ‘regressive transference neurosis’ and its resolution by means of interpretation alone, carried out by the analyst from a position of technical neutrality.

The concept of a regressive transference neurosis refers to the gradual gathering into the relationship with the analyst of the patient’s most important past pathogenic experiences and unconscious conflicts. The concept of a regressive transference neurosis has been largely abandoned in practice because, particularly in patients with severe character pathology, transference regression occurs so early and consistently that the gradual development of a regressive transference neurosis is no longer a useful concept.

Gill’s proposal that the resolution of the transference be achieved ‘by interpretation alone,’ refers to ‘interpretation’ as a set of the psychoanalyst’s interventions that starts with ‘clarification’ of the patient’s subjective experiences communicated by means of free association, expands with the tactful ‘confrontation’ of aspects of the patient’s patterns of behavior that are expressed in a dissociated or split off manner from his subjective awareness, and thus complements the total expression of his intrapsychic life in the treatment situation, and finally evolves into ‘interpretation per se.’ Interpretation per se implies the formulation of hypotheses regarding the unconscious meanings in the ‘here and now’ of the patient’s material, and the relation of these unconscious meanings with the ‘there and then’ of the patient’s unconscious, past pathogenic experiences.

The concept of ‘technical neutrality’ refers to the analyst’s impartiality regarding both impulse and defense, with a concerned objectivity that provides a helpful collaboration with the patient’s efforts to come to grips with his intrapsychic conflicts.

This definition of the nature of psychoanalytic treatment needs to be complemented with the contemporary concepts of ‘transference,’ ‘countertransference,’ ‘acting out’ and ‘working through.’

2.5 An Object Relations Theory Model Of The Transference And Countertransference

Modern object relations theory proposes that, in the case of any particular conflict around sexual or aggressive impulses, the conflict is imbedded in an internalized object relation, that is, in a repressed or dissociated representation of the self (‘self representation’) linked with a particular representation of another who is a significant object of desire or hatred (‘object representation’). Such units of self-representation, object representation and the dominant sexual, dependent or aggressive affect linking them are the basic ‘dyadic units,’ whose consolidation will give rise to the tripartite structure. Internalized dyadic relations dominated by sexual and aggressive impulses will constitute the id; internalized dyadic relations of an idealized or prohibitive nature the superego, and those related to developing psychosocial functioning and the preconscious and conscious experience, together with their unconscious, defensive organization against unconscious impulses, the ego. These internalized object relations are activated in the transference with an alternating role distribution, that is, the patient enacts a self representation while projecting the corresponding object representation onto the analyst at times, while at other times projecting his self representation onto the analyst and identifying with the corresponding object representation. The impulse or drive derivative is reflected by a dominant, usually primitive affect disposition linking a particular dyadic object relation; the associated defensive operation is also represented unconsciously by a corresponding dyadic relation between a self representation and an object representation under the dominance of a certain affect state.

The concept of countertransference, originally coined by Freud as the unresolved, reactivated transference dispositions of the analyst is currently defined as the total affective disposition of the analyst in response to the patient and his her transference, shifting from moment to moment, and providing important data of information to the analyst. The countertransference, thus defined, may be partially derived from unresolved problems of the analyst, but stems as well from the impact of the dominant transference reactions of the patient, from reality aspects of the patient’s life, and sometimes from aspects of the analyst’s life situation, that are emotionally activated in the context of the transference developments. In general, the stronger the transference regression, the more the transference determines the countertransference; thus the countertransference becomes an important diagnostic tool. The countertransference includes both the analyst’s empathic identification with a patient’s central subjective experience (‘concordant identification’) and the analyst’s identification with the reciprocal object or self representation (‘complementary identification’) unconsciously activated in the patient as part of a certain dyadic unit, and projected onto the analyst (Racker 1957). In other words, the analyst’s countertransference implies identification with what the patient cannot tolerate in himself herself, and must dissociate, project or repress.

At this point, it is important to refer to certain primitive defensive operations that were described by Klein (1952) and her school in the context of the analysis of severe character pathology. Primitive defensive operations are characteristic of patients with severe personality disorders, and emerge in other cases during periods of regression. They include splitting, projective identification, denial, omnipotence, omnipotent control, primitive idealization, and devaluation (contempt). All these primitive defenses center on splitting, i.e., an active dissociation of contradictory ego (or self ) experiences as a defense against unconscious intrapsychic conflict. They represent regression to the phase of development (the first two to three years of life) before repression and its related mechanisms mentioned are established.

Primitive defensive operations present important behavioral components that tend to induce behaviors or emotional reactions in the analyst, which, if the analyst manages to ‘contain’ them, permit him to diagnose in himself projected aspects of the patient’s experience. Particularly ‘projective identification’ is a process in which: (a) the patient unconsciously projects an intolerable aspect of self experience onto (or ‘into’) the analyst; (b) the analyst unconsciously enacts the corresponding experience (‘complementary identification’); (c) the patient tries to control the analyst, who now is under the effect of this projected behavior; and (d) the patient meanwhile maintains empathy with what is projected. Such complementary identification in the countertransference permits the analyst to identify himself through his own experience with the aspects of the patient’s experience communicated by means of projective identification. This information complements what the analyst has discovered about the patient by means of clarification and confrontation, and permits the analyst to integrate all this information in the form of a ‘selected fact’ that constitutes the object of interpretation. Interpretation is thus a complex technique that is very much concerned with the systematic analysis of both transference and countertransference.

2.6 Contemporary Trends Of The Psychoanalytic Method

Contemporary psychoanalytic technique can be seen as having evolved from a ‘one person psychology’ into a ‘two person psychology’ and then into a ‘three person psychology.’ The concept of ‘one person psychology’ refers to Freud’s original analysis of the patient’s unconscious intrapsychic conflicts by analyzing the intrapsychic defensive operations that oppose free association. The ‘two persons psychology’ refers to the central focus on the analysis of transference and countertransference. In the views of the contemporary intersubjective, interpersonal and self psychology psychoanalytic schools, the relationship between transference and countertransference is mutual, in the sense that the transference is at least in part a reaction to reality aspects of the analyst, who therefore must be acutely mindful of his contribution to the activation of the transference. The so-called ‘constructivist’ position regarding transference analysis assumes that it is impossible for the analyst to achieve a totally objective position outside the transference/countertransference bind.

In contrast, the contemporary ‘objectivist’ position, represented by the ‘three person psychology’ approaches of the Kleinian school, the French psychoanalytic mainstream, and significant segments of contemporary ego psychology proposes that the analyst has to divide himself between one part influenced by transference and countertransference developments, and another part that, by means of self reflection, maintains himself/herself outside this process, as an ‘excluded third party,’ who, symbolically, provides an early triangulation to the dyadic regression that dominates transference developments. This triangulation in the treatment situation becomes particularly important in the treatment of severe personality disorders.

The ‘repetition compulsion’ as a resistance of the id is very likely a form of acting out as a defense against emotional containment of an extremely painful or traumatic set of experiences. ‘Working through’ refers to the repeated elaboration of an unconscious conflict in the psychoanalytic situation. It is a major task for the analyst, who has to be alert to the subtle variation in meanings and implications of what on the surface may be appear to be an endless repetition of the same conflict in the transference. The patient elaboration of the conflict that presents itself with these repetitive characteristics also implies the function of ‘holding’ originally described by Winnicott (1965). It consists of the analyst’s capacity to withstand the onslaught of primitive transferences without retaliation, abandonment of the patient, or a self devaluing giving up, and the maintenance of a working relationship (or ‘therapeutic alliance’) that addresses itself consistently to the healthy part of the patient, even when the latter is under the control of his most conflicting behaviors. Bion’s (1967) concept of ‘containing’ is complementary to ‘holding,’ in the sense that holding deals mostly with the affective disposition of the analyst, and containing with his cognitive capacity to maintain a concerned objectivity and focus on the ‘selected fact,’ permitting the integration in the analyst’s mind what the patient can only express in violently dispersed or split off behavior patterns.

‘Dream analysis’ developed in the context of the method of free association, and constituted, in Freud’s (1953b) view, a ‘royal road to the unconscious.’ Freud’s discovery of primary process thinking derived from his method of dream analysis. By now, psychoanalytic thinking has evolved into the view that there are many ‘royal roads’ to the unconscious. The analysis of character defenses, for example, or of particular transference complications, may be equally important avenues of entry into the patient’s unconscious mind.

The technique of dream analysis consists, in essence, in asking the patient to free associate to elements of the ‘manifest content’ of the dream, in order to arrive at its ‘latent’ content, the unconscious wish defended against and distorted by the unconscious defensive mechanisms that constitute the ‘dream work,’ and have transformed the latent content into the manifest dream. The latent content is revealed with the help of the simultaneous analysis of the way in which the dream is being communicated to the analyst, the ‘day residuals’ that may have triggered the dream, the unconscious conflicts revealed in it, and the dominant transference dispositions in the context of which the dream evolved. Dreams also provide some residual, universal symbolic meanings that may facilitate the total understanding of the latent content.

‘The analysis of character’ may be the single most important element of the psychoanalytic method in bringing about fundamental characterological change. Character analysis is facilitated by the patient’s use of reaction formations, that is, his defensively motivated character traits, as transference resistances. Thus, the activation of defensive behaviors in the transference, reflecting the patient’s characterological patterns in all interpersonal interactions, facilitates both the analysis of the underlying unconscious conflicts, and in the process, the resolution of pathological character patterns. The result is an increase in the patient’s autonomy, flexibility, and capacity for adaptation.

The overall objective of psychoanalytic treatment is not only the resolution of symptoms and pathological behavior patterns or characteristics, but fundamental, structural change, that is, the expansion and enrichment of ego functions as the consequence of resolution of unconscious conflict and the integration of previously repressed and dynamically active id and superego pressures into ego potentialities. Such change is reflected in the increasing capacity for both adaptation to, and autonomy from, psychosocial demands and expectations, and an increased capacity for gratifying and successful functioning in love and work.

3. Treatment Results: Research On Outcome

The Menninger Psychotherapy Research Project, a naturalistic study comparing psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy, showed psychoanalysis to be the most effective of these approaches with patients presenting relatively good ego strength, while patients with severe ego weakness—what nowadays would be described as presenting severe personality disorders or borderline personality organization—improved most with psychoanalytic psychotherapy (Kernberg et al. 1972). That research also showed how important supportive elements were throughout all modalities of treatment (Wallerstein 1986). A comprehensive review of outcome studies on psychoanalytic psychotherapy and psychoanalysis by Bachrach and collaborators (Bachrach et al. 1985) concluded that the improvement rates are in the 60–90 percent range, but it also pointed to limitations and problems in the methodology utilized.

Recently, studies regarding the treatment process and outcome of psychoanalysis and psychoanalytic psychotherapy have become more precise in defining the specific treatment variables of psychotherapeutic and psychoanalytic treatments, and several systematic studies on psychoanalytic psychotherapies and psychoanalysis are in progress (Fonagy 1998). A recent study by the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (STOPPP) has found, on the basis of a relatively large patient population, that psychoanalytic treatment, in comparison with psychoanalytic psychotherapy, obtained a significantly higher degree long range symptomatic improvement (Sandell et al. 1997).


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