What's New? The Enduring Influence of Psychoanalysis

This article is co-authored by Chiara Staal, a psychologist in the Netherlands (first author).

Psychoanalysis has, to put it mildly, fallen out of favor. Whereas the ideas of Sigmund Freud and his many successors once dominated the academic and clinical landscape, many contemporary researchers and clinicians now largely dismiss psychoanalysis as a whole. As Paris (2017) has aptly noted, "Today, psychoanalysis has been marginalized and is struggling to survive in a hostile academic and clinical environment." At the same time, many modern psychological theories and treatment methods are at least partly rooted in these once fundamental ideas. Nevertheless, these origins often go unrecognized, and most practitioners ignore their psychoanalytic roots. All too often, this disavowal of psychoanalysis results in inadequate and oversimplified treatment.

We will argue here that a basic understanding of psychoanalytic theory is essential for effective clinical practice and that one should remain skeptical of diluted or superficial applications of its concepts. Some of the major clinical issues posed by modern therapies include a lack of attention to unconscious mental processes, the rejection of technical neutrality and abstinence, and an unfamiliarity with basic issues of transference and countertransference. To this end, we will first briefly describe some of the main characteristics of psychoanalytic treatment and then explore how some modern approaches, despite their psychoanalytic origins, may overlook key aspects of psychodynamic theory.

Goals and Principles of Psychoanalytic Therapy

Critics of psychoanalytic treatment tend to paint it as an endless, costly, and unscientific endeavor of personal-historical navel-gazing. Unfortunately, these criticisms are based on a fundamental misunderstanding of psychoanalytic methods of working. Psychoanalytic treatment does not attempt to reconstruct or dwell on the past. Rather, it is an approach that seeks to reveal problems encountered in the here and now and to understand them in light of past experiences. By becoming more fully aware of the ways in which prior experience has come to shape and color our understanding of the present, we might be able to free ourselves from the shackles of the past. Although history doesn't repeat itself, it does tend to rhyme.

Although psychoanalytic approaches are quite diverse, they are linked by a basic understanding that much of what drives our behavior, and hence our symptoms and problems, is hidden at a level that is outside of our awareness (attention to unconscious mental processes). Additionally, what happens between the therapist and the patient is vital to understanding the patient's modes of relating to self and others (transference and countertransference). The role of the therapist is not advice-giver but rather interpreter of the patient's communications. As such, the therapist's general stance is characterized by neutrality, abstinence, and relative anonymity (Gabbard, 1994).

Roots and Parallels of Modern Approaches

Cognitive therapy (CT), originally developed by Aaron Beck for the treatment of depression, helps patients identify and change problematic thought patterns that contribute to depressed mood. Beck, who had been enrolled in a psychoanalytic training program, believed CT to be a psychodynamically derived treatment in the ego psychology tradition. [An important aspect of ego psychology is strengthening what has been called the "observing ego," the ability to step outside of one’s thoughts and actions and to observe them (Lemma, 2016)]. Nevertheless, adaptations to CT gradually distanced it from its psychoanalytic roots, and most contemporary therapists are unaware of Beck's original conceptualization. As a result, many modern practitioners of CT and cognitive behavioral therapy (CBT) ignore the fundamental insights of psychoanalysis; rather than trying to integrate them, many fiercely oppose psychoanalytic concepts and techniques.

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In our opinion, CBT often tends to overlook issues of transference and countertransference, and greater emphasis is placed on the development of a positive working relationship than on using the relationship as a vehicle for change. This can lead to a treatment that overlooks vitally important aspects of the patient's relational life. Additionally, technical neutrality might be compromised by the heavily structured nature of CBT and other contemporary therapies, wherein there is often a preordained view on how treatment is supposed to be carried out and proceed, with a strong emphasis on the therapist's point of view (e.g., fixed interventions, homework assignments, and advice-giving).

Similarly, many of the ideas of Internal Family Systems (IFS) therapy, an increasingly popular approach, are borrowed from psychoanalysis, including the notion that human beings are composed of complex internal dynamics; the presence of competing and conflicting "parts" of self; the influence of early relationships; and a tendency to repeat emotionally salient patterns throughout life. Yet, we would argue that IFS tends to oversimplify all of these matters and lacks the theoretical nuance of the psychoanalytic models in which the approach is rooted. For example, IFS makes use of many preconceived metaphors (e.g., the naming of "parts") that might complicate meaning-making on an individual level. To this end, it fails to provide an overarching theoretical framework for effectively working with more complex cases, especially those involving severe psychopathology.

Supportive psychotherapy, too, was originally developed as a psychodynamic treatment focusing more on supporting healthy defenses than on the breaking down of pathological ones. It is perhaps the most widely practiced form of psychotherapy today, despite the fact that it is not frequently discussed or researched (Klapheke, 2023). Certainly, modern supportive approaches can deviate significantly from their original psychodynamic origins, but most modern practitioners of this type of therapy see it as a diametrically opposed treatment, when in fact it originally shared with psychoanalysis many fundamental assumptions about the workings of the human mind.

In some supportive therapies, there is now a tendency to collude with the patient's issues and defenses. Such a treatment might turn into supporting the patient's problems and pathology rather than supportively addressing them. We believe this is a growing issue in contemporary psychotherapy.

Chiara Staal

Source: Chiara Staal/Used with permission

Conclusion

Many modern schools of thought in psychotherapy have incorporated psychodynamic ideas without proper attribution. The practitioners of these approaches tend to deny or are otherwise unfamiliar with the role psychoanalysis played in the development of these modern treatments. Furthermore, some of the most important ingredients of psychoanalysis—the ingredients that more often than not are responsible for clinical improvement—are downplayed, ignored, or negated. We argue for greater awareness of these aspects of psychotherapy, as well as for greater recognition of the enduring influence of psychoanalysis, which continues to inform contemporary psychotherapy despite its common repudiation.