PSYCHOANALYTIC THERAPY

PSYCHOANALYTIC THERAPY

 

Key Concepts

View of Human Nature

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The Freudian view of human nature is basically deterministic. According to Freud, our behavior is determined by irrational forces, unconscious motivations, and biological and instinctual drives as these evolve through key psychosexual stages in the first six years of life.

Instincts are central to the Freudian approach. Although he originally used the term libido to refer to sexual energy, he later broadened it to include the energy of all the life instincts. These instincts serve the purpose of the survival of the individual and the human race; they are oriented toward growth, development, and creativity. Libido, then, should be understood as a source of motivation that encompasses sexual energy but goes beyond it. Freud includes all pleasurable acts in his concept of the life instincts; he sees the goal of much of life as gaining pleasure and avoiding pain.

Freud also postulates death instincts, which account for the aggressive drive. At times, people manifest through their behavior an unconscious wish to die or to hurt themselves or others. Managing this aggressive drive is a major challenge to the human race. In Freud’s view, both sexual and aggressive drives are powerful determinants of why people act as they do.

Structure of Personality

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According to the Freudian psychoanalytic view, the personality consists of three systems: the id, the ego, and the superego. These are names for psychological structures and should not be thought of as manikins that separately operate the personality; one’s personality functions as a whole rather than as three discrete segments. The id is roughly all the untamed drives or impulses that might be likened to the biological component. The ego attempts to organize and mediate between the id and

 

the reality of dangers posed by the id’s impulses. One way to protect ourselves from the dangers of our own drives is to establish a superego, which is the internalized social component, largely rooted in what the person imagines to be the expectations of parental figures. Because the point of taking in these imagined expectations is to protect ourselves from our own impulses, the superego may be more punitive and demanding than the person’s parents really were. Actions of the ego may or may not be conscious. For example, defenses typically are not conscious. Because ego and consciousness are not the same, the slogan for psychoanalysis has shifted from “making the unconscious conscious” to “where there was id, let there be ego.”

From the orthodox Freudian perspective, humans are viewed as energy systems. The dynamics of personality consist of the ways in which psychic energy is distributed to the id, ego, and superego. Because the amount of energy is limited, one system gains control over the available energy at the expense of the other two systems. Behavior is determined by this psychic energy.

The ID  The id is the original system of personality; at birth a person is all id. The id is the primary source of psychic energy and the seat of the instincts. It lacks organization and is blind, demanding, and insistent. A cauldron of seething excitement, the id cannot tolerate tension, and it functions to discharge tension immediately. Ruled by the pleasure principle, which is aimed at reducing tension, avoiding pain, and gaining pleasure, the id is illogical, amoral, and driven to satisfy instinctual needs. The id never matures, remaining the spoiled brat of personality. It does not think but only wishes or acts. The id is largely unconscious, or out of awareness.

The Ego  The ego has contact with the external world of reality. It is the “executive” that governs, controls, and regulates the personality. As a “traffic cop,” it mediates between the instincts and the surrounding environment. The ego controls consciousness and exercises censorship. Ruled by the reality principle, the ego does realistic and logical thinking and formulates plans of action for satisfying needs. The ego, as the seat of intelligence and rationality, checks and controls the blind impulses of the id. Whereas the id knows only subjective reality, the ego distinguishes between mental images and things in the external world.

The Superego  The superego is the judicial branch of personality. It includes a person’s moral code, the main concern being whether an action is good or bad, right or wrong. It represents the ideal rather than the real and strives not for pleasure but for perfection. The superego represents the traditional values and ideals of society as they are handed down from parents to children. It functions to inhibit the id impulses, to persuade the ego to substitute moralistic goals for realistic ones, and to strive for perfection. As the internalization of the standards of parents and society, the superego is related to psychological rewards and punishments. The rewards are feelings of pride and self-love; the punishments are feelings of guilt and inferiority.

Consciousness and the Unconscious

Perhaps Freud’s greatest contributions are his concepts of the unconscious and of the levels of consciousness, which are the keys to understanding behavior and the

 

problems of personality. The unconscious cannot be studied directly but is inferred from behavior. Clinical evidence for postulating the unconscious includes the following: (1) dreams, which are symbolic representations of unconscious needs, wishes, and conflicts; (2) slips of the tongue and forgetting, for example, a familiar name; (3) posthypnotic suggestions; (4) material derived from free-association techniques; (5) material derived from projective techniques; and (6) the symbolic content of psychotic symptoms.

For Freud, consciousness is a thin slice of the total mind. Like the greater part of the iceberg that lies below the surface of the water, the larger part of the mind exists below the surface of awareness. The unconscious stores all experiences, memories, and repressed material. Needs and motivations that are inaccessible—that is, out of awareness—are also outside the sphere of conscious control. Most psychological functioning exists in the out-of-awareness realm. The aim of psychoanalytic therapy is to make the unconscious motives conscious, for only then can an individual exercise choice. Understanding the role of the unconscious is central to grasping the essence of the psychoanalytic model of behavior.

Unconscious processes are at the root of all forms of neurotic symptoms and behaviors. From this perspective, a “cure” is based on uncovering the meaning of symptoms, the causes of behavior, and the repressed materials that interfere with healthy functioning. It is to be noted, however, that intellectual insight alone does not resolve the symptom. The client’s need to cling to old patterns (repetition) must be confronted by working through transference distortions, a process discussed later in this chapter.

Anxiety

Also essential to the psychoanalytic approach is its concept of anxiety. Anxiety is a feeling of dread that results from repressed feelings, memories, desires, and experiences that emerge to the surface of awareness. It can be considered as a state of tension that motivates us to do something. It develops out of a conflict among the id, ego, and superego over control of the available psychic energy. The function of anxiety is to warn of impending danger.

There are three kinds of anxiety: reality, neurotic, and moral. Reality anxiety is the fear of danger from the external world, and the level of such anxiety is proportionate to the degree of real threat. Neurotic and moral anxieties are evoked by threats to the “balance of power” within the person. They signal to the ego that unless appropriate measures are taken the danger may increase until the ego is overthrown. Neurotic anxiety is the fear that the instincts will get out of hand and cause the person to do something for which she or he will be punished. Moral anxiety is the fear of one’s own conscience. People with a well-developed conscience tend to feel guilty when they do something contrary to their moral code. When the ego cannot control anxiety by rational and direct methods, it relies on indirect ones—namely, ego-defense behavior.

Ego-Defense Mechanisms

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Ego-defense mechanisms help the individual cope with anxiety and prevent the ego from being overwhelmed. Rather than being pathological, ego defenses

 

are normal behaviors that can have adaptive value provided they do not become a style of life that enables the individual to avoid facing reality. The defenses employed depend on the individual’s level of development and degree of anxiety. Defense mechanisms have two characteristics in common: (1) they either deny or distort reality, and (2) they operate on an unconscious level. Table 4.1 provides brief descriptions of some common ego defenses.

 

 

Development of Personality

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Importance of Early Development  A significant contribution of the psychoanalytic model is delineation of the stages of psychosexual and psychosocial stages of development from birth through adulthood. The psychosexual stages refer to the Freudian chronological phases of development, beginning in infancy.

Freud postulated three early stages of development that often bring people to counseling when not appropriately resolved. First is the oral stage, which deals with the inability to trust oneself and others, resulting in the fear of loving and forming close relationships and low self-esteem. Next, is the anal stage, which deals with the inability to recognize and express anger, leading to the denial of one’s own power as a person and the lack of a sense of autonomy. Third, is the phallic stage, which deals with the inability to fully accept one’s sexuality and sexual feelings, and also to difficulty in accepting oneself as a man or woman. According to the Freudian psychoanalytic view, these three areas of personal and social development—love and trust,

 

dealing with negative feelings, and developing a positive acceptance of sexuality—are all grounded in the first six years of life. This period is the foundation on which later personality development is built. When a child’s needs are not adequately met during these stages of development, an individual may become fixated at that stage and behave in psychologically immature ways later on in life.

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Erikson’s Psychosocial Perspective  The developmental stages postulated by Freud have been expanded by other theorists. Erik Erikson’s (1963) psychosocial perspective on personality development is especially significant. Erikson built on Freud’s ideas and extended his theory by stressing the psychosocial aspects of development beyond early childhood. The psychosocial stages refer to Erikson’s basic psychological and social tasks, which individuals need to master at intervals from infancy through old age. This stage perspective provides the counselor with the conceptual tools for understanding key developmental tasks characteristic of the various stages of life. Erikson’s theory of development holds that psychosexual growth and psychosocial growth take place together, and that at each stage of life we face the task of establishing equilibrium between ourselves and our social world. He describes development in terms of the entire life span, divided by specific crises to be resolved. According to Erikson, a crisis is equivalent to a turning point in life when we have the potential to move forward or to regress. At these turning points, we can either resolve our conflicts or fail to master the developmental task. To a large extent, our life is the result of the choices we make at each of these stages.

Erikson is often credited with bringing an emphasis on social factors to contemporary psychoanalysis. Classical psychoanalysis is grounded on id psychology, and it holds that instincts and intrapsychic conflicts are the basic factors shaping personality development (both normal and abnormal). Contemporary psychoanalysis tends to be based on ego psychology, which does not deny the role of intrapsychic conflicts but emphasizes the striving of the ego for mastery and competence throughout the human life span. Ego psychology therapists assist clients in gaining awareness of their defenses and help them develop better ways of coping with these defenses (McWilliams, 2016). Ego psychology deals with both the early and the later developmental stages, for the assumption is that current problems cannot simply be reduced to repetitions of unconscious conflicts from early childhood. The stages of adolescence, mid-adulthood, and later adulthood all involve particular crises that must be addressed. As one’s past has meaning in terms of the future, there is continuity in development, reflected by stages of growth; each stage is related to the other stages.

Viewing an individual’s development from a combined perspective that includes both psychosexual and psychosocial factors is useful. Erikson believed Freud did not go far enough in explaining the ego’s place in development and did not give enough attention to social influences throughout the life span. A comparison of Freud’s psychosexual view and Erikson’s psychosocial view of the stages of development is presented in Table 4.2.

Counseling Implications  By taking a combined psychosexual and psychosocial perspective, counselors have a helpful conceptual framework for understanding developmental issues as they appear in therapy. The key needs and developmental tasks, along with the challenges inherent at each stage of life, provide a model for understanding some of the core conflicts clients explore in their therapy sessions. Questions such as these can give direction to the therapeutic process:

· ♦What are some major developmental tasks at each stage in life, and how are these tasks related to counseling?

· ♦What themes give continuity to this individual’s life?

· ♦What are some universal concerns of people at various points in life? How can people be challenged to make life-affirming choices at these points?

· ♦What is the relationship between an individual’s current problems and significant events from earlier years?

· ♦What choices were made at critical periods, and how did the person deal with these various crises?

· ♦What are the sociocultural factors influencing development that need to be understood if therapy is to be comprehensive?

 

The Therapeutic Process

Therapeutic Goals

The ultimate goal of psychoanalytic treatment is to increase adaptive functioning, which involves the reduction of symptoms and the resolution of conflicts

 

(Wolitzky, 2011a). Two goals of Freudian psychoanalytic therapy are to make the unconscious conscious and to strengthen the ego so that behavior is based more on reality and less on instinctual cravings or irrational guilt. Successful analysis is believed to result in significant modification of the individual’s personality and character structure. Therapeutic methods are used to bring out unconscious material. Then childhood experiences are reconstructed, discussed, interpreted, and analyzed. It is clear that the process is not limited to solving problems and learning new behaviors. Rather, there is a deeper probing into the past to develop the level of self-understanding that is assumed to be necessary for a change in character. Psychoanalytic therapy is oriented toward achieving insight, but not just an intellectual understanding; it is essential that the feelings and memories associated with this self-understanding be experienced.

Therapist’s Function and Role

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In classical psychoanalysis, analysts typically assume an anonymous non-judgmental stance, which is sometimes called the “blank-screen” approach. They avoid self-disclosure and maintain a sense of neutrality to foster a transference relationship, in which their clients will make projections onto them. This transference relationship is a cornerstone of psychoanalysis and “refers to the transfer of feelings originally experienced in an early relationship to other important people in a person’s present environment” (Luborsky, O’Reilly-Landry, & Arlow, 2011, p. 18). If therapists say little about themselves and rarely share their personal reactions, the assumption is that whatever the client feels toward them will largely be the product of feelings associated with other significant figures from the past. These projections, which have their origins in unfinished and repressed situations, are considered “grist for the mill,” and their analysis is the very essence of therapeutic work.

One of the central functions of analysis is to help clients acquire the freedom to love, work, and play. Other functions include assisting clients in achieving self-awareness, honesty, and more effective personal relationships; in dealing with anxiety in a realistic way; and in gaining control over impulsive and irrational behavior. Establishing a therapeutic alliance is a primary treatment goal, and repairing any damaged alliance is essential if therapy is to progress (McWilliams, 2014). The empathic attunement to the client facilitates the analyst’s appreciation of the client’s intrapsychic world (Wolitzky, 2011b). Particular attention is given to the client’s resistances. The analyst listens in a respectful, open-minded way and decides when to make appropriate interpretations; tact and timing are essential for effective interpretations (McWilliams, 2014). A major function of interpretation is to accelerate the process of uncovering unconscious material. The psychoanalytic therapist pays attention to both what is spoken and what is unspoken, listens for gaps and inconsistencies in the client’s story, infers the meaning of reported dreams and free associations, and remains sensitive to clues concerning the client’s feelings toward the therapist.

Organizing these therapeutic processes within the context of understanding personality structure and psychodynamics enables the analyst to formulate the nature of the client’s problems. One of the central functions of the analyst is to

 

teach clients the meaning of these processes (through interpretation) so that they are able to achieve insight into their problems, increase their awareness of ways to change, and thus gain more control over their lives. A primary aim of psychodynamic approaches is to foster the capacity of clients to solve their own problems.

The process of psychoanalytic therapy is somewhat like putting the pieces of a puzzle together. Whether clients change depends considerably more on their readiness to change than on the accuracy of the therapist’s interpretations. If the therapist pushes the client too rapidly or offers ill-timed interpretations, therapy will not be effective. Change occurs through the process of reworking old patterns so that clients might become freer to act in new ways (Luborsky et al., 2011).

Client’s Experience in Therapy

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Clients interested in classical psychoanalysis must be willing to commit themselves to an intensive, long-term therapy process. After some face-to-face sessions with the analyst, clients lie on a couch and engage in free association; that is, they try to say whatever comes to mind without self-censorship. This process of free association is known as the “fundamental rule.” Clients report their feelings, experiences, associations, memories, and fantasies to the analyst. Lying on the couch encourages deep, uncensored reflections and reduces the stimuli that might interfere with getting in touch with internal conflicts and productions. It also reduces the ability of clients to “read” their analyst’s face for reactions, which fosters the projections characteristic of a transference.

The client in psychoanalysis experiences a unique relationship with the analyst. The client is free to express any idea or feeling, no matter how irresponsible, scandalous, politically incorrect, selfish, or infantile. The analyst remains nonjudgmental, listening carefully and asking questions and making interpretations as the analysis progresses. This structure encourages the client to loosen defense mechanisms and “regress,” experiencing a less rigid level of adjustment that allows for positive therapeutic growth but also involves some vulnerability. It is a responsibility of the analyst to keep the analytic situation safe for the client, so the analyst is not free to engage in spontaneous self-expression. Every intervention by the therapist is made to further the client’s progress. In classical analysis, therapeutic neutrality and anonymity are valued by the analyst, and holding a consistent setting or “frame” plays a large part in this analytic technique. Therapeutic change requires an extended period of “working through” old patterns in the safety of the therapeutic relationship.

Psycho dynamic therapy emerged as a way of shortening and simplifying the lengthy process of classical psychoanalysis (Luborsky et al., 2011). Many psychoanalytically oriented practitioners, or psychodynamic therapists (as distinct from analysts), do not use all the techniques associated with classical analysis. However, psychodynamic therapists do remain alert to transference manifestations, explore the meaning of clients’ dreams, explore both the past and the present, offer interpretations for defenses and resistance, and are concerned with unconscious material. Traditional analytic therapists make more frequent interpretations of transferences and engage in fewer supportive interventions than do psychodynamic therapists (Wolitzky, 2011a).

 

Clients in psychoanalytic therapy make a commitment with the therapist to stick with the procedures of an intensive therapeutic process. They agree to talk because their verbal productions are the heart of psychoanalytic therapy. They are typically asked not to make any radical changes in their lifestyle during the period of analysis, such as getting a divorce or quitting their job. The reason for avoiding making such changes pertains to the therapeutic process that oftentimes is unsettling and also associated with loosening of defenses. These restrictions are less relevant to psychoanalytic psychotherapy than to classical psychoanalysis. Psychoanalytic psychotherapy typically involves fewer sessions per week, the sessions are usually face to face, and the therapist is supportive; hence, there is less therapeutic “regression.”

Psychoanalytic clients are ready to terminate their sessions when they and their analyst mutually agree that they have resolved those symptoms and core conflicts that were amenable to resolution, have clarified and accepted their remaining emotional problems, have understood the historical roots of their difficulties, have mastery of core themes, have insight into how their environment affects them and how they affect the environment, have achieved reduced defensiveness, and can integrate their awareness of past problems with their present relationships. Wolitzky (201 la) lists other optimal criteria for termination, including the reduction of transference, accomplishing the main goals of therapy, an acceptance of the futility of certain strivings and childhood fantasies, an increased capacity for love and work, achieving more stable coping patterns, and a self-analytic capacity. Successful analysis answers a client’s “why” questions regarding his or her life. Curtis and Hirsch (2011) suggest that termination tends to bring up intense feelings of attachment, separation, and loss. Thus a termination date is set well enough in advance to talk about these feelings and about what the client learned in psychotherapy. Therapists assist clients in clarifying what they have done to bring about changes.

Relationship Between Therapist and Client

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There are some differences between how the therapeutic relationship is conceptualized by classical analysis and contemporary relational analysis. The classical analyst stands outside the relationship, comments on it, and offers insight-producing interpretations. In contemporary relational psychoanalysis, the therapist does not strive for an objective stance. Contemporary psychodynamic therapists focus as much on here-and-now transference as on earlier reenactment. By bringing the past into the present relationship, a new understanding of the past can unfold (Wolitzky, 2011a). Contemporary psychodynamic therapists view their emotional communication with clients as a useful way to gain information and create connection. Analytic therapy focuses on feelings, perceptions, and action that are happening in the moment in the therapy sessions (Luborsky et al., 2011McWilliams, 2014Wolitzky, 2011a2011b). The therapeutic relationship is central to increasing client self-awareness, self-understanding, and exploration (Barber, Muran, McCarthy, & Keefe, 2013). Current findings of interpersonal neurobiology lend strong support for the effectiveness of the psychoanalytic relationship when treating clients who have suffered interpersonal trauma and neglect (Schore, 2014).

 

Transference and countertransference are central to understanding psychodynamic therapy. A significant aspect of the therapeutic relationship is manifested through transference reactions. Transference is the client’s unconscious shifting to the analyst of feelings, attitudes, and fantasies (both positive and negative) that are reactions to significant others in the client’s past. Transference involves the unconscious repetition of the past in the present. “It reflects the deep patterning of old experiences in relationships as they emerge in current life” (Luborsky et al., 2011, p. 47). A client often has a mixture of positive and negative feelings and reactions to a therapist. When these feelings become conscious and are transferred to the therapist, clients can understand and resolve past “unfinished business.” As therapy progresses, childhood feelings and conflicts begin to surface from the depths of the unconscious, and clients regress emotionally. Transference takes place when clients resurrect these early intense conflicts relating to love, sexuality, hostility, anxiety, and resentment; bring them into the present; reexperience them; and attach them to the therapist. For example, clients may transfer unresolved feelings toward a stern and unloving father to the therapist, who, in their eyes, becomes stern and unloving. Angry feelings are the product of negative transference, but clients also may develop a positive transference and, for example, fall in love with the therapist, wish to be adopted, or in many other ways seek the love, acceptance, and approval of an all-powerful therapist. In short, the therapist becomes a current substitute for significant others.

If therapy is to produce change, the transference relationship must be worked through. The working-through process consists of repetitive and elaborate explorations of unconscious material and defenses, most of which originated in early childhood. Clients learn to accept their defensive structures and recognize how they may have served a purpose in the past (Rutan, Stone, & Shay, 2014). This results in a resolution of old patterns and enables clients to make new choices. Effective therapy requires that the client develop a relationship with the therapist in the present that is a corrective and integrative experience.

Clients have many opportunities to see the variety of ways in which their core conflicts and core defenses are manifested in their daily life. It is assumed that for clients to become psychologically independent they must not only become aware of this unconscious material but also achieve some level of freedom from behavior motivated by infantile strivings, such as the need for total love and acceptance from parental figures. If this demanding phase of the therapeutic relationship is not properly worked through, clients simply transfer their infantile wishes for universal love and acceptance to other figures. It is precisely in the client-therapist relationship that the manifestation of these childhood motivations becomes apparent.

Regardless of the length of psychoanalytic therapy, traces of our childhood needs and traumas will never be completely erased. Infantile conflicts may not be fully resolved, even though many aspects of transference are worked through with a therapist. We may need to struggle at times throughout our life with feelings that we project onto others as well as with unrealistic demands that we expect others to fulfill. In this sense we experience transference with many people, and our past is always a vital part of the person we are presently becoming.

It is a mistake to assume that all feelings clients have toward their therapists are manifestations of transference. Many of these reactions may have a reality base, and

 

clients’ feelings may well be directed to the here-and-now style the therapist exhibits. Not every positive response (such as liking the therapist) should be labeled “positive transference.” Conversely, a client’s anger toward the therapist may be a function of the therapist’s behavior; it is a mistake to label all negative reactions as signs of “negative transference.”

The notion of never becoming completely free of past experiences has significant implications for therapists who become intimately involved in the unresolved conflicts of their clients. Even if the conflicts of therapists have surfaced to awareness, and even if therapists have dealt with these personal issues in their own intensive therapy, they may still project distortions onto clients. Therapists’ countertransference reactions are inevitable because all therapists have unresolved conflicts and personal vulnerabilities that are activated through their professional work. From a traditional psychoanalytic perspective, countertransference is viewed as a phenomenon that occurs when there is inappropriate affect, when therapists respond in irrational ways, or when they lose their objectivity in a relationship because their own conflicts are triggered. Countertransference consists of a therapist’s unconscious emotional responses to a client based on the therapist’s own past, resulting in a distorted perception of the client’s behavior (Rutan et al., 2014). Over the years this traditional view of countertransference has broadened to include all of the therapist’s reactions, not only to the client’s transference, but to all aspects of the client’s personality and behavior. In this broader perspective, countertransference involves the therapist’s total emotional response to a client and may include withdrawal, anger, love, annoyance, powerlessness, avoidance, overidentification, control, or sadness. In today’s psychoanalytic practice, countertransference is manifested in the form of subtle nonverbal, tonal, and attitudinal actions that inevitably affect clients, either consciously or unconsciously (Curtis & Hirsch, 2011Wolitzky, 2011b).

To avoid misunderstanding and overidentification with clients, the analytic approach requires therapists to undergo their own analytic psychotherapy. McWilliams (2014) emphasizes how important it is for therapists to access and understand their unconscious and suggests that a key outcome of therapy is humility, which provides a good foundation for creating authentic, egalitarian, and healing connections with clients. Personal therapy and clinical supervision for therapists can be helpful in better understanding how internal reactions influence the therapy process and how to use these countertransference reactions to benefit the work of therapy (Hayes, Gelso, & Hummel, 2011).

Not all countertransference reactions are detrimental to therapeutic progress. Indeed, countertransference reactions are often the strongest source of data for understanding the world of the client and for self-understanding on the therapist’s part. For example, a therapist who notes a countertransference mood of irritability may learn something about a client’s pattern of being demanding, which can be explored in therapy. Viewed in this more positive way, countertransference can become a key avenue for helping the client gain self-understanding. Most research on countertransference has dealt with its deleterious effects, but Hayes (2004) suggests it would be useful to undertake systematic study of the potential therapeutic benefits of countertransference.

Psychoanalytic therapists vary in the manner in which they use their observations of countertransference. In some instances the feelings may be shared with

 

the client, but traditional analytic therapists strive to minimize their expression of countertransference while silently learning from its inevitable occurrence. The ability of therapists to gain self-understanding and to establish appropriate boundaries with clients is critical in managing and effectively using their countertransference reactions (Hayes et al., 2011).

It is of paramount importance that therapists develop some level of objectivity and not react defensively and subjectively in the face of anger, love, adulation, criticism, and other intense feelings expressed by their clients. If psychotherapists become aware of a strong aversion to certain types of clients, a strong attraction to other types of clients, psychosomatic reactions that occur at definite times in therapeutic relationships, and the like, it is imperative for them to seek professional consultation, clinical supervision, or enter their own therapy for a time to work out these personal issues that stand in the way of their being effective therapists.

Through the client-therapist relationship, clients acquire insights into the workings of their unconscious processes. Awareness of and insights into repressed material are the bases of the analytic growth process. Clients come to understand the association between their past experiences and their current behavior. The psychoanalytic approach assumes that without this dynamic self-understanding there can be no substantial personality change or resolution of present conflicts.

Application: Therapeutic Techniques and Procedures

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This section deals with the techniques most commonly used by psychoanalytically oriented therapists. It also includes a section on the applications of the psychoanalytic approach to group counseling. Psychoanalytic or psychodynamic therapy differs from traditional psychoanalysis in these ways:

· ♦The therapy has more to limited objectives than restructuring one’s personality.

· ♦The therapist is less likely to use the couch.

· ♦There are fewer sessions each week.

· ♦There is more frequent use of supportive interventions such as reassurance, expressions of empathy and support, and suggestions.

· ♦There is more emphasis on the here-and-now relationship between therapist and client.

· ♦There is more latitude for therapist self-disclosure without “polluting the transference.”

· ♦Less emphasis is given to the therapist’s neutrality.

· ♦There is a focus on mutual transference and countertransference enactments.

· ♦The focus is more on pressing practical concerns than on working with fantasy material.

The techniques of psychoanalytic therapy are aimed at increasing awareness, fostering insights into the client’s behavior, and understanding the meanings of symptoms. The therapy proceeds from the client’s talk to catharsis (or expression of emotion), to insight, to working through unconscious material. This work is done

 

to attain the goals of intellectual and emotional understanding and reeducation, which, it is hoped, will lead to personality change. The six basic techniques of psychoanalytic therapy are (1) maintaining the analytic framework, (2) free association, (3) interpretation, (4) dream analysis, (5) analysis of resistance, and (6) analysis of transference. See Case Approach to Counseling and Psychotherapy (Corey, 2013, chap. 2) for an illustration by Dr. William Blau, a psychoanalytically oriented therapist, of some treatment techniques in the case of Ruth.

Maintaining the Analytic Framework

The psychoanalytic process stresses maintaining a particular framework aimed at accomplishing the goals of this type of therapy. Maintaining the analytic framework refers to a whole range of procedural and stylistic factors, such as the analyst’s relative anonymity, maintaining neutrality and objectivity, the regularity and consistency of meetings, starting and ending the sessions on time, clarity on fees, and basic boundary issues such as the avoidance of advice giving or imposition of the therapist’s values (Curtis & Hirsch, 2011). One of the most powerful features of psychoanalytically oriented therapy is that the consistent framework is itself a therapeutic factor, comparable on an emotional level to the regular feeding of an infant. Analysts attempt to minimize departures from this consistent pattern (such as vacations, changes in fees, or changes in the meeting environment). Where departures are unavoidable, these will often be the focus of interpretations.

Free Association

Free association is a central technique in psychoanalytic therapy, and it plays a key role in the process of maintaining the analytic framework. In free association, clients are encouraged to say whatever comes to mind, regardless of how painful, silly, trivial, illogical, or irrelevant it may seem. In essence, clients try to flow with any feelings or thoughts by reporting them immediately without censorship. As the analytic work progresses, most clients will occasionally depart from this basic rule, and these resistances will be interpreted by the therapist when it is timely to do so.

Free association is one of the basic tools used to open the doors to unconscious wishes, fantasies, conflicts, and motivations. This technique often leads to some recollection of past experiences and, at times, a catharsis or release of intense feelings that have been blocked. This release is not seen as crucial in itself, however. During the free-association process, the therapist’s task is to identify the repressed material that is locked in the unconscious. The sequence of associations guides the therapist in understanding the connections clients make among events. Blockings or disruptions in associations serve as cues to anxiety-arousing material. The therapist interprets the material to clients, guiding them toward increased insight into the underlying dynamics.

As analytic therapists listen to their clients’ free associations, they hear not only the surface content but also the hidden meaning. Nothing the client says is taken at face value. For example, a slip of the tongue can suggest that an expressed emotion is accompanied by a conflicting affect. Areas that clients do not talk about are as significant as the areas they do discuss.

 

Interpretation

Interpretation consists of the analyst’s pointing out, explaining, and even teaching the client the meanings of behavior that is manifested in dreams, free association, resistances, defenses, and the therapeutic relationship itself. The functions of interpretations are to enable the ego to assimilate new material and to speed up the process of uncovering further unconscious material. Interpretation is grounded in the therapist’s assessment of the client’s personality and of the factors in the client’s past that contributed to his or her difficulties. Under contemporary definitions, interpretation includes identifying, clarifying, and translating the client’s material. Relational psychoanalytic therapists present possible meanings associated with a client’s thoughts, feelings, or events as a hypothesis rather than a truth about a client’s inner world (Curtis & Hirsch, 2011). Interpretations are provided in a collaborative manner to help clients make sense of their lives and to expand their consciousness.

The therapist uses the client’s reactions as a gauge in determining a client’s readiness to make an interpretation. It is important that interpretations be appropriately timed because the client will reject therapist interpretations that are poorly timed. A general rule is that interpretation should be presented when the phenomenon to be interpreted is close to conscious awareness. In other words, the therapist should interpret material that the client has not yet seen but is capable of tolerating and incorporating. Another general rule is that interpretation should start from the surface and go only as deep as the client is able to go.

Dream Analysis

Dream analysis is an important procedure for uncovering unconscious material and giving the client insight into some areas of unresolved problems. During sleep, defenses are lowered and repressed feelings surface. Freud sees dreams as the “royal road to the unconscious,” for in them one’s unconscious wishes, needs, and fears are expressed. Some motivations are so unacceptable to the person that they are expressed in disguised or symbolic form rather than being revealed directly.

Dreams have two levels of content: latent content and manifest content. Latent content consists of hidden, symbolic, and unconscious motives, wishes, and fears. Because they are so painful and threatening, the unconscious sexual and aggressive impulses that make up latent content are transformed into the more acceptable manifest content, which is the dream as it appears to the dreamer. The process by which the latent content of a dream is transformed into the less threatening manifest content is called dream work. The therapist’s task is to uncover disguised meanings by studying the symbols in the manifest content of the dream.

During the session, therapists may ask clients to free associate to some aspect of the manifest content of a dream for the purpose of uncovering the latent meanings. Therapists participate in the process by exploring clients’ associations with them. Interpreting the meanings of the dream elements helps clients unlock the repression that has kept the material from consciousness and relate the new insight to their present struggles. Dreams may serve as a pathway to repressed material, but dreams also provide an understanding of clients’ current functioning. Relational

 

psychoanalytic therapists are particularly interested in the connection of dreams to clients’ lives. The dream is viewed as a significant message to clients to examine something that could be problematic if left unexamined (Curtis & Hirsch, 2011).

Analysis and Interpretation of Resistance

Resistance, a concept fundamental to the practice of psychoanalysis, is anything that works against the progress of therapy and prevents the client from producing previously unconscious material. Specifically, resistance is the client’s reluctance to bring to the surface of awareness unconscious material that has been repressed. Resistance refers to any idea, attitude, feeling, or action (conscious or unconscious) that fosters the status quo and gets in the way of change. During free association or association to dreams, the client may evidence an unwillingness to relate certain thoughts, feelings, and experiences. Freud viewed resistance as an unconscious dynamic that people use to defend against the intolerable anxiety and pain that would arise if they were to become aware of their repressed impulses and feelings.

As a defense against anxiety, resistance operates specifically in psychoanalytic therapy to prevent clients and therapists from succeeding in their joint effort to gain insights into the dynamics of the unconscious. An assumption of analytic treatment is that clients wish both to change and to remain embedded in their old world. Clients tend to cling to their familiar patterns, regardless of how painful they may be. Therapists need to create a safe climate so clients can recognize resistance and explore it in therapy (Curtis & Hirsch, 2011McWilliams, 2014Wolitzky, 2011a). Because resistance blocks threatening material from entering awareness, analytic therapists point it out, but Safran and Kriss (2014) caution therapists to avoid framing resistance in a way that implies that the client is not cooperating with the treatment. Therapists’ interpretations help clients become aware of the reasons for the resistance so they can deal with them. As a general rule, therapists point out and interpret the most obvious resistances to lessen the possibility of clients’ rejecting the interpretation and to increase the chance that they will begin to look at their resistive behavior.

Resistances are not just something to be overcome. Because they are representative of usual defensive approaches in daily life, they need to be recognized as devices that defend against anxiety but that interfere with the ability to accept change that could lead to experiencing a more gratifying life. It is crucial that therapists respect the resistances of clients and assist them in working therapeutically with their defenses. When handled properly, exploring resistance can be an extremely valuable tool in understanding the client.

Analysis and Interpretation of Transference

As was mentioned earlier, transference manifests itself in the therapeutic process when earlier relationships contribute to clients distorting the present with the therapist. The transference situation is considered valuable because its manifestations provide clients with the opportunity to reexperience a variety of feelings that would otherwise be inaccessible. Through the relationship with the therapist, clients express feelings, beliefs, and desires that they have buried in their unconscious.

 

Interpreting transference is a route to elucidating the client’s intrapsychic life (Wolitzky, 2011b). Through this interpretation, clients can recognize how they are repeating the same dynamic patterns in their relationships with the therapist, with significant figures from the past, and in present relationships with significant others. Through appropriate interpretations and working through of these current expressions of early feelings, clients are able to become aware of and to gradually change some of their long-standing patterns of behavior. Analytically oriented therapists consider the process of exploring and interpreting transference feelings as the core of the therapeutic process because it is aimed at achieving increased awareness and personality change.

The analysis of transference is a central technique in both classical psychoanalysis and psychoanalytically oriented therapy, for it allows clients to achieve here-and-now insight into the influence of the past on their present functioning. Interpretation of the transference relationship enables clients to work through old conflicts that are keeping them fixated and retarding their emotional growth. In essence, the effects of early relationships are counteracted by working through a similar emotional conflict in the current therapeutic relationship. An example of utilizing transference is given in a later section on the case of Stan.

Application to Group Counseling

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