Introduction
Let us start with some of the questions this book tries to address. What is psychoanalysis, does it matter, and if so, why? Is psychoanalysis a 21st-century-relevant concern, or a historical curiosity now superseded by more efficient, evidence-based ways of thinking about mental life and about how suffering can best be alleviated? Is it not an elitist backwater, requiring its participants to be able to afford to spend 3–5 hours per week reflecting on their inner lives and paying for the privilege? Does it open up the possibility of radical reassessment and transformation of how we live our lives, or does the time and intensity of reflection required of the analysand actually militate against change? Is psychoanalysis not guilty of uncritically reproducing and universalising historically and culturally specific – and now long-outdated – assumptions about, for example, sexuality, gender, and the division of labour? Is it not trapped in outdated 19th-century ideas about instincts? Does the psychoanalytic focus on structural change increase the likelihood of the results of treatment enduring, or does its apparent lack of interest in directly alleviating symptoms not show a cavalier disregard for patients’ suffering?
These are just a few of the questions typically asked about psychoanalysis today, pointing to its continuing capacity to provoke lively debate well over 100 years after its birth in an obscure private neurology practice in fin-de-siècle Vienna. Notwithstanding fairly regular declarations that Freud is dead, there is plenty of evidence that the ideas that he gave birth to, and others subsequently developed, are very much alive. To take just one example, in 2012, when the Maudsley Hospital in London, the premier psychiatric research institution in the world, organised a public debate on the motion “This house believes that psychoanalysis has a valuable place in modern mental health services”, it was attended by 350 people – and as many more had to be turned away. The expectation in this bastion of biological psychiatry was that the speakers against the motion would carry the day, but the final vote was overwhelmingly in favour of psychoanalysis. Setting aside the question of the outcome of the debate, it illustrates that feelings about psychoanalysis continue to run high.
At times, discussions of the nature of psychoanalysis have a distinct flavour of the blind men feeling the elephant. By “psychoanalysis” we can mean a body of theoretical ideas, a set of therapeutic practices or principles of practice, a quasi-ideological movement, or an institution. The way psychoanalysis is perceived affects the conclusions reached. If we consider the use of the couch and a frequency of four or five sessions per week to be essential to the definition of psychoanalysis, this may limit our capacity to consider the potential value of both its clinical and non-clinical applications. If we maintain that in the absence of transference interpretation what transpires in the consulting room cannot be psychoanalysis, this will have a significant impact on our ideas about who is likely to benefit from it. If we insist that any psychoanalysis worthy of the name must concern itself with the fate of the patient’s infantile sexuality, this will give the treatment quite a different flavour to an approach focused on the development of a sense of self as one separates from one’s primary caregiver; and so on. There is a lack of consensus about both the common theoretical ground and the definition of psychoanalytic – as distinct from other forms of psychotherapeutic – practice, and intense disagreements about which institutions have the authority to decide what does or does not constitute psychoanalysis.
Despite this squabbling, much of which is fuelled by what Freud (1918, p. 199) aptly called “the narcissism of minor differences”, there continues to be an eager appetite among other academic and therapeutic disciplines such as literature, anthropology, sociology, and linguistics for psychoanalytic perspectives, and interest in psychoanalysis is growing in areas of the world where it has not traditionally had much of a foothold, such as in China, where there is increasing demand for psychoanalytic training and supervision. Recent phenomena such as the reckless investing behaviour that led to the financial crisis of 2008, the rise of nationalism and various forms of political extremism, the alarming growth of hate speech, misogyny, racism, and xenophobia, and the wide range of emotional reactions to the impact of the Covid-19 pandemic, have revealed the limitations of models of human behaviour based on the assumption that human beings are rational animals. Developments in neuroscience have opened up the possibility of a rapprochement of Freudian ideas with the discipline from which they originally sprang.
One of the deepest and most foundational psychoanalytic insights is that conflict structures the human mind. Freud believed that resistance to psychoanalysis was inevitable because psychoanalysis shines a light on those aspects of ourselves that we would rather not know about or share with others. As he listened to the patients who visited his neurology practice, and thought about their symptoms and dreams – both theirs and his own – he became more and more convinced that our thinking is influenced by processes of which we are not consciously aware, that we are actively invested in remaining unaware of these processes, and that we will resist efforts to make us aware, even if we agree in theory that knowing more about what shapes and motivates us might be a good thing. These two insights – the conflictual nature of the human psyche and the role of the unconscious – remain as valid and, we would say, relevant today as when Freud first formulated them.
Freud saw psychic conflict as the enduring legacy of our helplessness and dependency in infancy. Humans are an altricial species – that is, infants are completely dependent on their caregivers for a long period of time. Once we are able to fend for ourselves, we tend to want to forget the time when we were not able to, and yet we are indelibly marked by it. The experiences we have with our primary caregivers are shaped by our temperament and genetic makeup (i.e., Freud’s “constitution”) as well as by our caregivers’ responses. This intense interpersonal biobehavioural matrix of infancy and early childhood forms templates – which are more or less modifiable – for future relationships and being in the world. Our struggle as young children to understand and come to terms with our complicated feelings about our earliest love objects and our place in the family lays the foundations of enduring psychic structures that will determine the characteristics of our later attachment relationships. Here, again, current trends are favourable to an increased receptiveness to psychoanalytic perspectives, with growing recognition of the developmental nature of mental health problems. Longitudinal research has shown that three-quarters of mental health problems can be traced back, in an additive way, to “adverse childhood events” (Kim-Cohen et al., 2003).
In infancy, we were dependent on our caregivers as attachment figures to help manage the physical and emotional needs we were not yet equipped to cope with. The psychological processes revealed by psychoanalysis apply equally to adult life. For example, we may attribute the feelings in ourselves that we would rather not know about to some other person (projection) and then attack the other person for supposedly having them. As well as being useful in helping to make sense of what happens psychoanalytically, ideas like these are often helpful for mental health professionals struggling with bewilderingly difficult feelings about their work, even if the therapeutic technique they are using is not technically psychoanalytic. Other modalities, such as cognitive-behavioural therapy, are beginning to use some of the theoretical and clinical features of the psychoanalytic approach.
In sum, there is plenty of evidence that the psychoanalytic perspective continues to be valued and that the current climate of opinion is, if anything, more favourable to what psychoanalysis may uniquely have to offer than it was when the first edition of this book was published. Our aim in this second edition remains to present the core features of contemporary psychoanalytic theory and practice, a bedrock that might then form the basis for a wider discussion about the nature and role of psychoanalysis within psychiatry, psychotherapy, and society. In this introductory chapter, we will review some of the key issues of debate and controversy that currently preoccupy psychoanalysis. To put these discussions into context, as well as being a backdrop to the whole book, we start with a brief account of the history and evolution of the psychoanalytic movement.
