What Is Psychoanalysis?

A crash course inspired by a conversation at a party.

Posted Dec 17, 2017

"On the one hand, psychoanalysis is practical in the sense that there is an attempt to solve a problem, or to cure somebody, or at least to address their suffering. But the other thing that psychoanalysis does is that the project is to enable somebody to speak. It's the attempt to create the conditions in which somebody can speak themselves as fully as possible."

                                                   —Adam Phillips

What do you do when you meet a psychoanalyst at a party?

Circle all that apply:

  1. Avoid a prolonged conversation and/or hide and/or flee.
  2. Feel uncomfortable yet enticed, and talk about yourself.
  3. Be genuinely curious and secure.
  4. Make a joke about whether they are analyzing you or requesting "free therapy" and see how the analyst responds.
  5. Ask them about your therapy.
  6. Make a joke about your parents.
  7. Make a joke about the analyst's parents.
  8. Make a joke about Oedipus.
  9. Make a joke about sex.
  10. Make an unacceptable joke.
  11. Trash Freud.
  12. Exalt Freud.
  13. Turn the tables and (try) to analyze him or her (good luck).
  14. Ask them what the difference is between psychiatry and psychology.
  15. Ask them what psychoanalysis is.
  16. Act normal.
  17. Decide if the analyst seems normal.
  18. Offer your services.
  19. Other (specify).

I was at a holiday party the other day, and a charismatic, highly effective young business consultant asked me what psychoanalysis is, and how you would know if it worked. Since I did not have a 30 second elevator talk prepared (my bad), I explained to him that psychoanalysis is a highly individualized form of talk therapy which involves typically meeting one-on-one with a trained psychoanalyst a few to several times per week, to talk about oneself and whatever else you want to talk about. Psychoanalysts can come from many professional backgrounds. Used to be mainly physicians, more recently dominated by psychologists, and increasing interest from social workers and other mental health professionals. In some states, "lay analysts" can be licensed to practice psychoanalysis, and came come from any professional background if they meet basic educational requirements (often a Master's degree).

Outcome measures are not established, and could range from evidence-based measures of quality of life, interpersonal and individual functioning, personality change, behavioral outcomes, and psychiatric measures to existential issues to learning to be yourself, and more. Where and when I grew up, everyone had an analyst, and they probably worked with everyone in the family at some point. That was probably a necessary but not sufficient condition for me to say, when asked at 11 what I wanted to be when I grew up, a "psychoanalyst". Why, after all, would a pre-teen be reading about the work of Sigmund Freud and Carl Jung in books he bought at a suburban mall in a now not-existent book store chain?

That's a whole other story, but the point is, don't they teach what psychoanalysis is in high school health class? Or, maybe not? Woody Allen movies, TV serials, and pop cultural aren't doing their job, apparently. Hence, this blog, which I fear is too abstruse to be of any real value to all but a few. Maybe the next version will be more accessible. We'll see.

I described to this bright young person how part of the work of psychanalysis is to ask what the work is about, and that the reasons people begin an analysis are often not the reasons they remain in analysis. Because analysis can last many years, as well, people will go through stage of life changes over the course of the analytic treatment, defying short-term outcome measures. Each analytic experience is to a significant extent self-defined within general parameters, which is really amazing under the right circumstances. For other things, it isn't suitable.

He asked how I though analysis might be "scalable", for example if I conducted a webinar with multiple participants, all doing psychoanalysis with me at the same time, perhaps using a questionnaire with multiple choices to help shape how relevant psychological information elicited and used in the process. I said that would be great (let's do it) but I thought it might be more group therapy or coaching, rather than psychoanalysis—which to me is by definition a two-person process involving a particular kind of close relationship requiring a lot of one-on-one time.

Psychoanalysis is an intimate relationship, with strong boundaries and restrictions on what is allowed, and presumably once you have a professional analytic relationship, that is all the relationship can ever be. Really, from a purist point of view, the only thing you are "allowed" to do is talk—about anything, perhaps, but nothing else. This can be frustrating, and anxiety-provoking, but in a very real and important way is very, very safe.

And still, psychoanalysis at it heart is very simple—the "talking cure". It's like cellular automata (e.g. The Game of Life)—there are a few simple rules, and great complexity arises from setting up that system and letting it run. Two people meet and agree to talk openly together in a way intended to be helpful to one of them struggling with some difficulty in life, working within a generally structured professional framework with few specific rules. Unlike other forms of therapy, psychoanalysis is open-ended, often lasting over a decade, involving meeting a few times a week, and without necessarily any pre-defined goals. It is also possible to view psychoanalysis as a non-clinical discipline, not a form of therapy but rather a certain kind of conversation one may choose to engage in with another person, for any reason whatsoever. 

I described Freud's "Fundamental Rule" which gives participants not only the freedom and the right, but possibly charges us with the moral imperative to say without censoring oneself whatever comes to mind. If you can't do that—it can take a while to be able to master the skill of free association—then try to note when you are editing yourself, and why. If you can do that, it's pretty awesome.

The analyst, in counterpoint, is meant to listen with evenly hovering attention, a quasi-meditative, quasi-trancelike attentive-counterattentive state in which the analyst listens directionlessly, takes no notes, and makes no effort to select what information attention is paid to; it's also pretty cool when you think about it:

"It will be seen that the rule of giving equal notice to everything is the necessary counterpart to the demand made on the patient that he should communicate everything that occurs to him without criticism or selection. If the doctor behaves otherwise, he is throwing away most of the advantage which results from the patient's obeying the ‘fundamental rule of psychoanalysis’. The rule for the doctor may be expressed: ‘He should withhold all conscious influences from his capacity to attend, and give himself over completely to his 'unconscious memory'. Or, to put it purely in terms of technique: ‘He should simply listen, and not bother about whether he is keeping anything in mind.’ "

"To put it in a formula: he must turn his own unconscious like a receptive organ towards the transmitting unconscious of the patient. He must adjust himself to the patient as a telephone receiver is adjusted to the transmitting microphone. Just as the receiver converts back into sound waves the electric oscillations in the telephone line which were set up by sound waves, so the doctor's unconscious is able, from the derivatives of the unconscious which are communicated to him, to reconstruct that unconscious, which has determined the patient's free associations."

                                                    —Freud, 1912

Psychoanalysis is a great way to learn about your own inner life, one without substitute because of the highly personalized and idiosyncratic nature of the relationship. Spending so much time with one person, often over the course of years, saying everything one's mind in an atmosphere of professionally-boundaried intimacy and interpersonal safety is one of the most incredible learning experiences a person can have. And remember, most of the work of psychoanalysis takes place outside of the scheduled time. Even if you meet a few times a week. The seemingly unstructured mental activity, far from random, is understood upon reflection both at times within the formal meeting, but also on one's own. This is also part of why breaks (e.g. vacations) are times when a lot of change can gel. Development while progressive is an evolutionary process, tending to plateau and climb, sometimes appear to roll back, before advancing again.

I also talked about personality, and discussed that psychoanalysis can help people to change through self-recognition. Psychoanalysis uses the key framework of "working with the transference," a powerful tool for self-understanding. Transference is what the patient brings to analysis from prior important relationships, typically of key developmental importance (parents, siblings, other family members, important teachers, friends, etc.). Patients "transfer" these characteristics onto the analyst, who to varying degrees backgrounds her or his own personality to allow the patient's internal relationship models to play out in the psychoanalytic relationship via transferential dynamics. This playing out is called "enactment" and by understanding and discussing transference and enactment, we can see beyond our own blind spots. The analyst in turn pays attention to her or his "countertransference", including developmental experiences and reactions to the patient which can influence the analysis process. Countertransference can either be factored-out of the work, taken into consideration as useful data, or potentially create problems if the analyst's own issues negatively impact the treatment.

Psychoanalysis, closely related to psychodynamic psychotherapy, looks at how unrecognized emotions and developmental experiences live on in our psyches and play our in our lives, often with unintended negative consequences including various forms of self-sabotaging and relationship-interfering behaviors. Psychoanalysis traditionally also invites patients to "bring their dreams into therapy", as dreams can be used as a window into the unconscious mind. Although psychoanalytic work is generally not highly directive (like coaching or CBT), psychoanalysis elevates the patient's own agency, allowing us to come to know ourselves in a naturally-unfolding process without pressure to change. Over time, on the romantic ideal side, this can be transformative as we discover who we really are and changes happen organically; on the flip side, people can go for years in psychoanalysis and get a really good sense of what their issues are without necessarily making any concrete, useful changes in their lives.

Jonathan Shedler describes the key features of psychoanalytic psychotherapy in his instant-class controversial paper The Efficacy of Psychodynamic Therapy:

  1. Focus on affect and expression of emotion.
  2. Exploration of attempts to avoid distressing thoughts and feelings.
  3. Identification of recurring themes and patterns.
  4. Discussion of past experience (developmental focus).
  5. Focus on interpersonal relations.
  6. Focus on the therapy relationship.
  7. Exploration of fantasy life.

Birds of a feather

Psychoanalysis has had a rich and storied history, and it's as much about the players as it is about the theories and techniques. It's not really possibly to only study the different schools without understanding who was and is involved; to do so loses something essential because psychoanalysis is quintessentially about the individual, even in relational models. The clinical work is always only focused on one person's life and progress.

Different models of analytic work generally spell out theories and provide examples of clinical work. However, because it is such a personalized process dependent on the particulars of the two people involved, regardless of the frame in which they work, every psychoanalyst has their own style and way of working, and every psychoanalytic treatment is unique. As Freud (1912) noted,

"I must however make it clear that what I am asserting is that this technique is the only one suited to my individuality; I do not venture to deny that a physician quite differently constituted might find himself driven to adopt a different attitude to his patients and to the task before him."

There is also good evidence for the effectiveness of psychoanalytic therapy as a clinical treatment, though no therapy will work for everyone. As it stands currently, structured therapies, most notably cognitive behavioral therapy, get the lion's share of evidence-based recommendations for a variety of reasons. It's not my purpose to get into that debate here, but Jonathan Shedler gives an account of the state of affairs in the "therapy wars" here, discussing the limitations of research on psychotherapy and how that gives a distorted perspective of what "evidence-based" means for the field.

In the next section, we'll look at some of the major psychoanalytic schools to give readers a sense of what the differences are, though they all fall under the umbrella of psychoanalysis. There are too many different analytic schools to discuss them all, and psychoanalysis is enjoying vibrant rejuvenation and application in humanities programs. Aside from the analytic schools noted below, it's important to note that analysis is taking root internationally, and Asian and South American analytic institutes, and the theorists associated with those schools, bring different perspectives to the work.

There is no global psychoanalytic model, as different international associations tend to have greater allegiance to one school of thought or another, though that is gradually shifting. The field seems to do well when there are groups which are more focused on one area, and groups who are more focused on legitimizing multiple models standing side-by-side, or synthesizing, though this leads to tumultuous and contentious dynamics, and sometimes unhealthy rivalry, among different schools. This internal conflict within the field, there from the very first days in Freud's inner circle, remains highly problematic because political and personal issues present the field from effective collaboration. It's also bad PR because you'd think psychoanalysts ought to be able to get along better with one another, but I guess most psychoanalysts are used to working in pairs.

Aside from important differences in theory and clinical technique, different schools of psychoanalysis generally started out of dissent and abuse of power. People with new ideas were not permitted to develop their work within their own schools, and went on to start their own institutions with like-minded colleagues, ironically often going on to become similarly narrow-minded and exclusionary, rather than become more inclusive and flexible, and thus repeating the same pattern of exclusionism. In spite of the idealism surrounding self-discovery and the freedom and utility of the analytic experience, as with all other human institutions, politics and personality rule the day, while at the same time psychoanalytic institutions provide community for their members.

Different analytic brands

Ego Psychology: Based on Freud's work, as developed primarily in the United States in the mid-20th century, ego psychology is based on a model of the psyche having conscious, preconscious and unconscious processes, divided into the ego, the id and the superego. The id contains the basic drives, and is likened to a primitive and libidinous set of motivations which are regulated by the demands of reality (the reality principle). Every drive has an object, for example the sexual drive has other people as the "object" of the drive, and the term "object" has come to mean another person in English translations. The ego develops to mediate between reality and the psyche, and the superego represents internalized morality, typically from the parents and society. If these parts of the mind are imbalanced, people will have difficulties, for example either being too impulsive if the id's drives are not properly regulated, or too repressed with an overbearing, excessively punitive superego. 

The work of psychoanalysis in ego psychology is most closely modeled on the fundamental rule, and the analyst typically listens and makes infrequent interpretations based on theory in order to help the patient come to understand unconscious psychodynamic influences (defenses) which shape behavior, thus making the unconscious conscious and permitting the patient to develop more mature defenses and better function in multiple areas, becoming less neurotic over time. Interpretations are directed at the most accessible "preconscious" level, which is at the boundary between conscious and unconscious, and therefore least difficult because the associated emotional states are more tolerable.

Important developmental experiences and the expression of unconscious forces are typically seen as being "repressed" from memory, buried within the unconscious, and as the analysis proceeds they are "uncovered" through the iterative process of free association and interpretation. Ego psychology has been critiqued for paying too much attention to the individual, and not enough attention to relationships, though this is hotly debated among analytic schools. In principle, any analyst could provide psychoanalytic treatment for any patient, expecting to practice according to technique with a consistent outcome each time, suggesting that the choice of analyst or fit between patient and analyst is not very relevant.

Pierre Janet: Janet, one of the "fathers" of modern psychology, was a contemporary of Freud's known for his work on dissociation. While his work did not develop into a formal psychoanalytic school, his work with hysteria, hypnosis, dissociation, the subconscious, and other concepts was influential in shaping depth psychology, and figures such as Freud and Jung were familiar with his work. In recent times, there has been a resurgence of interest in his work in trauma-informed psychotherapy, work with patients with dissociative disorders, and in relational psychoanalysis.

Analytic Psychology: Jungian analysis is called "analytic psychology". Focusing on dreams and mythic work, Carl Jung's ideas have been very influential outside of psychoanalysis. Concepts such as archetypes, personas, and collective unconscious have worked their way into our culture as have Freudian ideas. Jung's work underlies the Myers-Briggs personality model often used in business. Jung and Freud had a complicated and ultimately irreparable relationship, and while Jung was Freud's intended successor, the broke with one another.

Lacanian psychoanalysis: Based on the work of self-proclaimed Freudian Jacques Lacan, a French psychoanalyst, Lacanian psychoanalysis is dense and philosophical, drawing upon structuralism and post-structuralism to examine the meaning of psychic experience. Using semiotic terms such as "signifier" and "signified", Lacan discussed meaning as being slippery and referential. He discussed experience as having three aspects: the Real, the Imaginary and the Symbolic. Notably, the Real is that which we can never know, which resists signification (a signified with a signifier), contained within the unconscious mind. He is known for using the term jouissance to connote an excessive, transgressive experience related to joy which is so intense that it cannot be fully tolerated and known, leading to a degree of disintegration.

Object Relations: Based on the work of Melanie Klein and others (e.g. Wilfred Bion, a military psychiatrist who also was key to the development of group therapy and organizational psychology), object relations moves a step further than ego psychology toward a relationship-based model, but maintains the focus on the contents of the individual psyche. Patterns from key developmental experiences, typically relationships with mother and father, as well as other figures, are internalized as unconscious patterns in the patient's psyche. Interpretations focus on these internalized object relations as they are played on in the transference.

Object relations work is stereotypically know for "deep" interpretations, which go into the deep unconscious and can be shocking and difficult to take in, and so analysts in this tradition, as a cliché, are known for saying strange things about early childhood experiences, for example suggesting that the patient's anger at the analyst for going on vacation is actually about early childhood experiences of deprivation.

Interpersonal psychoanalysis: Based on the work of Harry Stack Sullivan and other clinicians (for example Erich Fromm), the interpersonal model (not to be confused with interpersonal therapy) is fundamentally based on the influence of actual developmental experiences, especially formative relationships with parents and other family members, and notably with peers, as Sullivan pointed out the importance of "chums" to development. Interpersonal analysis does not use the Freudian model of the mind, rather people develop "security operations" to "selectively inattend" (rather than repress) elements of experience which are too anxiety-provoking for awareness.

Sullivan notes that people have three broad areas of self-awareness: good me, bad me, and not me. Good me refers to aspects of oneself which are positive, bad me to aspects of oneself which are negative, and not me aspects of oneself which are too terrifying to be aware of, but which nonetheless play out in interpersonal relations. The work of analysis takes place as a more interactive process in which the analyst listens to the patient closely, and asks carefully crafted questions to open up new areas of understanding, a process known as the "detailed inquiry". The view of the self in interpersonal psychoanalysis is more fluid. Rather than having a singular self or ego, the self is seen as fundamentally interpersonal, and we all can take on different self-states in different social settings. Rather than discussing transference, Sullivan focused on the clarity of interpersonal communication a feature of distortions in relationships, defining three layers of experience ranging from non-verbal (prototaxic), to distorted in various ways which lend to miscommunication (parataxic), and syntaxic (clear, consensually-validated communication). The analyst remains an expert consultant in the interpersonal model, though more involved than the stereotypical "blank slate" Freudian analyst.

Self-Psychology: Predominantly based on the work of Heinz Kohut which came to fruition in the late 1960s and early 1970s, self-psychology was developed to treat narcissism, thought to be unsuitable for traditional psychoanalytic approaches. Kohut emphasized steering clear of working with shameful, injured aspects of the self, noticing that bringing this material to the patient's attention may be too emotionally difficult to be useful, and would often lead to a break-down in treatment. Instead, he focused on the analyst working as a good "selfobject", reflecting the best aspects of the patient over time in order to foster developmental growth in stronger areas of the self, allowing the more vulnerable areas to improve indirectly as sense of self improved.

His approach focuses on the analyst's use of empathy to repair narcissistic issues, based on the idea that psychopathology comes primarily from the parents' failure to empathize during child development. By being a good selfobject, the patient is able to idealize the therapist and form a reparative relationship in which narcissistic issues improve over time. The work of psychoanalyst and pediatrician Donald Winnicott is influential in many theories, and with self-psychology his concept of transitional objects (prototypically teddy bears and blankets used to comfort oneself in the absence of the primary caregiver and (maternal) holding environments describes a course of analytic work characterized by inevitable failures in empathy, and efforts to address those failures in therapy results (when successful) in positive developments.

Intersubjectivity theory comes out of philosophy and self-psychology, discussing the development of a shared analytic space in which there is room for appreciation of one another's individual subjectivity, even in the presence of conflict. There is room for multiple perspectives. In parallel with capacity for free association, the ability to engage in intersubjective relatedness may be viewed as a developmental achievement. Atwood and Stolorow pioneered this area with their work starting in the mid 1980s, and among other things draw upon complexity theory in presenting a "meta-theory" of psychoanalysis.

Relational Psychoanalysis: Relational psychoanalysis has its roots in Freudian, interpersonal, object relational and self-psychology, to put it simply, and began in the 1980s out of an effort to synthesize different theories presented in the seminal work of Greenberg and Mitchell, Object Relations in Psychoanalytic Theory (1983). Even more than interpersonal analysis, relational models emphasize the basic equality of both participants, and relational analysts stereotypically are seen as being warmer and more empathic, more likely to focus on the real (versus transferential or fantasy) aspects of the relationship between the two people, and to be interested in discussing what is happening and how it is viewed by both participants as a key element in the analytic process. Freud discussed that love itself may be curative in analytic work, and that theme has been explored explicitly in more contemporary models. What is love (baby don't hurt me)?

Being able to use the relationship, and enactments which happen within the relationship, is seen as being an effective way of facilitating change. Some contemporary interpersonal-relational analysts have emphasized the value of spontaneity, openness to immediate experience (consonant with free association) and improvisation. Rather than being "about the analyst", discussion of the intimate aspects of the psychoanalytic relationship provides avenues for learning and growth not possibly within traditional models which would avoid the rich sources of information coming from sharing of one another's experience, understanding how that shapes the relationship, looking at ruptures within the relationship and learning from the process of recovery, and seeing how developmental patterns play out in the relationship. By being open to sharing aspects of personal experience and exploring one another's responses, while maintaining a boundaried, safe professional relationship, there is more room in the analytic relationship to make sure that important issues are open to discussion. Attachment theory is increasingly referenced in psychoanalytic models as well, with particular applications for interpersonal-relational models. The fit between the patient and therapist is of primary importance, along with how they navigate difficulties.

Recent relational models draw upon intersubjectively alongside the work of Donald Winnicott (and other very rich and well-articulated relational theory) more fully in looking at the role of mutual recognition ("recognition theory") in addressing potentially abusive power dynamics, important in working with patients who have experienced various forms of relational trauma. Relational models draw upon social constructivist, post-modern and hermeneutical philosophical traditions, as well.

Other notable developments include work in neuropsychoanalysis, mentalization-based therapies, gender theory, social justice, public mental health, making psychoanalysis more accessible to broader groups, and trauma and dissociation-based psychoanalytic approaches, to gloss over several major areas.

Be fruitful and multiply

So, that was the short version. Psychoanalysis comes alive as a participatory experience, whether with other actual people or while engaging in study and reflection. That doesn't mean necessarily "being analyzed"; discussion about psychoanalysis can be intellectually satisfying and personally meaningful without any formal clinical element—so please contact me if you would like to discuss a webinar, speaking engagement, or corporate workshop! Learning about psychoanalysis, I reflect on my own experience, and develop greater insight and awareness. Psychoanalysis arguably has a solid evidence-base, but still struggles to regain legitimacy in clinical centers.

The personal analytic work I've done lives on inside of me and continues to provide benefit in many different ways—which by the way is also what research on analysis shows. Long-term psychotherapeutic work has been shown to have ongoing positive effects for an extended time after the completion of the formal work. That's the power of relationship, harnessed within the psychoanalytic paradigm.

I hope that answers the question.

References

Freud, S. (1912). Recommendations to Physicians Practising Psycho-Analysis. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works, 109-120

Shedler, J. (2010). The efficacy of psychodynamic therapy. American Psychologist, Feb-March, Vol. 65, No. 2, 98-109.