Introduction to the Practice of Psychoanalytic Psychotherapy

Alessandra Lemma

• Editorial: Wiley
• Año: 2013
• ISBN:
  9781118687697
• Edición: 1
• Categoría: Psicología
• Categoría: Psicoterapia

A clear and thorough introduction to techniques and practice issues, as well as basic theoretical frameworks, for beginners. Psychoanalysis is not so much skill-based, as dependent upon the development of the analytic attitude, guided by principles of technique that are used in the clinical situation.

Alessandra Lemma's accessible guide has been based on her long experience of teaching trainee practitioners. It includes discussion of interventions and the possible dynamics associated with the different stages of therapy: assessment, beginnings, middle and end phases of therapy. It exposes the rationale underlying a range of interventions and discusses research evidence where relevant and available.

• Written by a well known author with plenty of practical experience
• Introductory and aimed at trainees
• Uniquely, it combines practical advice with theoretical explanation

1

AN OVERVIEW OF THE SCHOOLS OF PSYCHOANALYSIS: THEORY AND PRACTICE

1. THEORY

Psychoanalysis in Context

Psychoanalysis is often approached critically by those who are not involved with it. This is partly because it is perceived as an exclusive, precious club whose membership consists of people who regard themselves as having access to truths about human nature and the process of psychotherapy that are lost on the average non-psychoanalytic clinician. There is some truth in this perception but it is not altogether accurate as the psychoanalytic membership includes a broad range of people with different values and attitudes. Its membership is in some respects incontrovertibly privileged: it consists mostly of people who are sufficiently socio-economically advantaged to undertake a lengthy training that requires a second mortgage. There is little doubt too that psychoanalysis has all too often adopted a dismissive – even arrogant – attitude to related fields of enquiry and to other therapeutic modalities. Nowadays, psychoanalytic training institutions are acutely aware of the dwindling numbers in the applications to train psychoanalytically. Keenness to recruit more students into the analytic fold has contributed to a muchneeded review of admission procedures and the content and process of training.

Psychoanalysis is currently negotiating a transitional phase. Entrenched theoretical positions, perhaps owing more to political agendas than anything else, are gradually being challenged and opened up for evaluation. Cross-fertilisation of ideas between different schools and between different disciplines is gaining momentum. This change is exciting and unsettling: some practitioners are reaching out for the new while others remain fiercely attached to cherished assumptions, seemingly impervious to what other fields of enquiry might have to offer psychoanalysis.

Despite these efforts, psychoanalytic institutions remain more inaccessible, and more inward looking than is desirable for the growth of the profession. Understanding this predicament requires some appreciation of the inauspicious beginnings of psychoanalysis. From the outset, Freud provoked dissent and criticism. His views were indeed challenging and provocative. They were considered to be all the more so because he was Jewish. Freud was acutely aware of the effect of his Jewish roots on the acclaim of his ideas. When his friend and colleague, the Swiss psychiatrist Carl Jung – the only non-Jew then affiliated to the psychoanalytic movement – left Freud’s following in 1914, Freud was concerned that psychoanalysis would be considered as no more than a “Jewish national affair”.

Freud may well have wanted to play down the Jewish connection, but this fact was at the forefront of other peoples’ minds. In the 1930s, with the rise of the Nazis, psychoanalysis was attacked: Freud’s writings, together with those of Einstein, H.G. Wells, Thomas Mann and Proust, were burnt in public bonfires for their “soul disintegrating exaggeration of the instinctual life” (Ferris, 1997). Along with Darwin, Freud was vilified for subverting the high values of the fair-skinned races. His position in Vienna became untenable. On March 12, 1938, German troops moved into Austria. On March 13,1938, the Board of the Psychoanalytic Society met for the last time. Freud likened their predicament to that of Rabbi Johannan ben Zakkai who fled Jerusalem after the Romans destroyed the temple and he began a religious school in his place of refuge. Freud urged his colleagues to follow this example. In a strong vote of confidence, the Board, before dissolving, agreed that the Society should reconstitute wherever Freud settled.

Freud was reluctant to leave Vienna, but a week later, when the Gestapo took away his daughter, Anna Freud, for questioning, he no longer needed persuading. By the time Anna was released the following day, plans were afoot for Freud to go into exile. Travelling via Paris, Freud fled to London. Many of his colleagues were also forced into exile. They moved to America, Britain, Palestine, Australia and South America. Those analysts who remained in Germany practised but only under strict Nazi requirements: classical Freudian analysis itself was deemed unacceptable.

The very real persecution suffered by the psychoanalytic movement in its infancy left a deep scar. From the outset, Freud saw psychoanalysis as a cause to be defended against attack and the analytic institutes that emerged could be seen to be the “bastions” of this defence (Kirsner, 1990). This had the unfortunate effect of also keeping at bay other perspectives and related fields of enquiry, fearing their evaluation, criticism and attack.

The movement’s paranoia has not just been a feature of its relationship with the outside, non-analytic world. It has also been a striking quality of the relationships within the psychoanalytic establishment itself amongst its own rival theoretical offspring. The history of psychoanalysis is one of schisms. Indeed, psychoanalysis is an umbrella term covering a number of theoretical schools which, whilst all originating from and honouring some of Freud’s ideas, have since evolved very different theories about personality development and different techniques for achieving the goals of psychoanalysis as a treatment for psychological problems.

The development of psychoanalysis in Britain is a very good example of the difficulties of living in a pluralistic society (Hamilton, 1996). The British Psychoanalytic Society was established by Ernest Jones. Since its inception, three distinct groups – the Contemporary Freudians, the Kleinians and the Independents¹ – have had to live together within one society with the unavoidable tensions associated with living in close proximity to neighbours who do not necessarily share the same point of view. It is to their credit that they have managed to co-exist within one society.

Each group represents a heterogeneous mix of practitioners most of whom have been influenced both by relational and developmental perspectives within psychoanalysis, as well as including those who lean more specifically towards contemporary Kleinian thinking. There are only a small number of older Freudians who were trained by, and remain loyal to, Anna Freud and who would be more appropriately referred to as “Classical Freudians”. In North America, ego psychology and self psychology have a stronger presence, whilst Kleinian ideas have been slower on the uptake, though recent publications suggest a greater espousal of these ideas (e.g. Caper, 2000). Overall, heterogeneity dominates psychoanalytic theory, where within-group differences are sometimes as striking as between-group differences. This adds to the richness of analytic thinking but raises the thorny question of which theory, if any, reflects back to us the most valid model of the mind and of development.

The aim of this chapter is to provide an all too brief overview of the development of psychoanalytic ideas from Freud onwards to the present day. Of necessity, only the ideas of a few of the key players in the history of psychoanalysis are presented. To simplify this overview, the two most influential theories have been grouped as Freudian and Kleinian, respectively, with the focus on only a few of the most salient concepts propounded by these two dominant figures. Unfortunately, this is at the cost of glossing over the many Freudian and Kleinian theories that exist and those approaches that have grown out of these early beginnings. We will therefore only be covering, in broad terms, some of the most common assumptions of these two main theories and, only cursorily, some of the post-Freudian and Kleinian developments. This overview, by virtue of its attempt to synthesise, glosses over the subtler differences that do exist between the various schools and veers towards simplifying complex concepts. For those interested in metapsychology, it is therefore not a substitute for a careful reading of both Freud’s and Klein’s original texts.

The Early Years: Freud’s Topographical Model of the Mind

Freud proposed two models of the mind to account for the experience of intrapsychic conflict. The first model is known as the topographical model consisting of three levels of consciousness. The first level, the conscious, corresponds to that which we are immediately aware of, whatever we may be concentrating on at any given moment – for instance, reading this chapter. Beneath the conscious level lies the preconscious, consisting of whatever we can voluntarily recall. That is, the preconscious acts as a kind of storage bin for all those memories, ideas and sense impressions that are readily available to us, but to which we are simply not attending all the time. Beneath the preconscious lies the unconscious.

Freud used the term unconscious in three different senses. Firstly, he used it descriptively to denote that which is not in our consciousness at any given moment but is nonetheless available to us. This is no longer a controversial notion in contemporary psychology. Cognitive neuroscience has shown that most of the working brain is non-conscious in this sense; for example, memory can be acquired without any conscious awareness and thinking, decision making and problem solving all involve unconscious aspects (Milner et al., 1998). Even our processing of emotional experience has been shown to occur unconsciously in an automatic way (Solms & Turnbull, 2002). Moreover, this type of processing is qualitatively different from conscious processing at the level of the neuro-mechanisms involved (Milner et al., 1998).

Secondly, Freud used the term unconscious in a systemic sense denoting his understanding of the unconscious, not as a gradation of consciousness, but as a hypothetical system of the mind with particular properties. Finally, he used the term to denote the dynamic unconscious, that is, a constant source of motivation that makes things happen. Freud understood the inability to recall the contents of the unconscious voluntarily as the outcome of an active force that attempted to keep the contents of the unconscious from reaching consciousness, that is, repression. The unconscious in this sense is said to contain sexual and aggressive drives, defences, memories and feelings that have been repressed.

The preconscious and the conscious systems both obey the usual rules of thinking, namely, logical, reality tested and linear in time and causality. These rules are typical of what is referred to as secondary process thinking. The unconscious system obeys a different set of rules typical of primary process thinking. In this part of our mind, information is not subject to any kind of reality testing so that mutually exclusive “truths” may coexist and contradictions may abound. Because of these properties, the unconscious has been likened to an infantile and primitive part of our mind.

Towards Ego Psychology: Freud’s Structural Model of the Mind

In his paper, The Ego and the Id, Freud (1923b) gave an account of his shift away from the topographical model to the structural hypothesis.² This new model conceptualised the human psyche as an interaction of three forces: the id, ego and superego. These are three different agencies of our personalities, each with its own agenda and set of priorities. They were said to have their own separate origins and their own highly specific role in maintaining what might be regarded as “normal” personality functioning. Difficulties arise because of the potential conflict between the demands of the different agencies. Within the structural model, a conflict refers to the opposition of two or more intrapsychic³ aims. In this model, interaction with the external world is given more prominence as Freud argued that conflicts could arise from external pressures as well as from internal ones.

The id

According to Freud, each one of us is endowed with a specific amount of psychic energy. In the newborn infant, psychic energy is bound up entirely in the id, which refers to the mass of biological drives (sexual and aggressive) with which we are all born. A drive is an internally generated biological force that seeks discharge. An accumulation of drive tension is subjectively experienced as a state of unpleasure, whereas its discharge is experienced as pleasurable. All drives possess four core characteristics:

• A source in the body.
• An aim (i.e. a particular mode of gratification).
• A pressure (i.e. a quantitative level of excitement).
• An object (i.e. that which allows the aim to be realised).

The id is pre-verbal, expressing itself in images and symbols. It is prelogical, having no concept of time or limitations. It is not amenable to reason, logic, reality or morality. It is essentially a primitive kind of cognition, which is not well suited to the exigencies of reality. The id is only concerned with one thing: the reduction of whatever tensions our organism may experience. Our innate tendency to maximise pleasure and minimise pain was referred to as the pleasure principle by Freud. He believed that the infant, in the first year of life, was primarily narcissistic, its psychic functioning governed by the pleasure principle, with no differentiation between inner and outer – a view that has since been radically challenged by developmental psychologists who have demonstrated that the baby is from birth actively seeking engagement with others and is aware of other people.

The id is entirely unconscious. Its contents can be considered to be equivalent to the unconscious of Freud’s earlier topographical model. Its existence is inferred from derivatives such as dreams or slips of the tongue. The energy of the id is divided between two types of instincts: the life and the death instincts. The life instinct is aimed at survival and self-propagation. The energy of the life instinct, the libido, was considered by Freud to be the driving force permeating our entire personalities and propelling us through life. In his earliest formulations, Freud spoke of our basic drive as being entirely sexual and all other aims and desires as arising from some modification of our sexual drive. Among Freudian therapists nowadays, the term libido has lost a great deal of its original sexual connotations and refers essentially to the idea of drive energy;⁴ that is, the energy we may invest in the pursuit of our particular interests in some topic, activity or in a relationship with others. Freud believed that we cathect, that is, we invest, people, objects or ideas with psychic energy. Cathexis refers to the amount of psychic energy that becomes attached to the mental representative of a person or object that is, to the memories, thoughts or fantasies about a person. This investment of psychic energy is an indication of the emotional importance of the person or object to the individual in question.

In opposition to the life instinct stands the death instinct. Discussions of the death instinct, including Freud’s, tend to be rather vague. It is clear, however, that Freud saw the human organism as instinctively drawn back to a state in which all tension would be dissipated – in short, the state of death. This instinctive attraction towards death gives rise to self-directed aggressive tendencies. However, since self-destruction is opposed and tempered by the life-preserving energy of the libido, our aggression, in most instances, is redirected outward against the world. Aggressive instincts are a component of what drives behaviour. Our self-preservative instinct relies on a measure of aggression at its disposal to fulfil its aims. Aggression thus also has a “propelling function” (Perelberg, 1999), which is essential to preserve life.

The death instinct represents Freud’s broadest philosophical speculation. Amongst Contemporary Freudians, few still hold on to the notion of a death instinct and find it much more useful to talk about, and to work with, such concepts as guilt, aggression, anger or conflict with the superego. It is the Kleinians who have developed the notion further; they implicitly invoke the notion of a death instinct when discussing self and other destructive behaviours, which are seen to be a derivative of the operation of the death instinct.

The ego

While the id knows what it wants and needs, it is in some respects “blind” – blind to what constitutes safe or ethical ways of getting what it wants since it takes no account of reality. To fulfil this function, Freud suggested that the mind developed a new psychic component, the ego, which he believed emerged at about six months of age. The ego is responsible for voluntary thought and action and is in contact with the external world via the senses. It is concerned with key mental functions such as perception, reality testing, sense of time, thinking and judgement. Freud’s interest in reality becomes clearer in the structural model as he placed more emphasis than hitherto on the strength of the ego in relation to the other agencies of the personality.

The central function of the ego is to serve as a mediator between the id and reality. In contrast to the id’s pleasure principle, the ego operates on what is called the reality principle. Because the ego’s role is to adapt to reality, an important aspect of functioning that psychoanalytic therapists are interested in assessing is the patient’s ego strength, namely, his capacity to acknowledge reality without falling back on the extensive use of defences, especially the more primitive ones (see Chapters 5 & 7).

The ego has both conscious and unconscious aspects. The conscious ego is closest to what we usually refer to as the “self”, whereas the unconscious ego encompasses defensive processes. The terms “ego” and “self” are often used interchangeably and lead to considerable confusion, partly due to Freud’s own ambiguous use of the German term “ich”. Hartmann (1950) differentiated the ego and the self according to their interactional context. Within this framework, the ego interacted with the other intrapsychic agencies (id and superego) while the “self” was said to interact with objects.⁵

The superego

Freud suggested that as we grow up, we take into ourselves ideas and attitudes held by others around us. The formation of the superego is an instance of what is called introjection, that is, as children we absorb our parents’ standards and values and these come together to form the superego. Parents are thought to play an important role in curbing or inhibiting the id’s excesses, helping the child to become attuned to the demands of reality.

The rules, the abstract moral principles and the ideal image of whom we ought to be can be thought of as a person inside us who has strong views and is always ready to criticise, if our behaviour is not up to standard. This person inside us is equivalent to our superego. The superego is divided into two parts: an ego ideal representing what the ego aspires to and a conscience that punishes the ego when it fails.

Like the ego, the superego is partly conscious⁶ and partly unconscious. While most of us have some awareness of the moral rules and standards that govern our behaviour, there are other moral, sometimes harsh or persecutory, internal forces that bear on us of which we are unaware.

The psychosexual stages of development

Freud’s belief that our sexual life begins at birth led him to describe what are referred to as the stages of psychosexual development. He argued that we all progress through a series of stages; at each stage, our psyche directs its sexual energy towards a different erogenous zone, that is, a part of our body, which is a source of pleasure. Freud first proposed the oral stage (0–1 years) where satisfaction is predominantly derived by the infant via the mouth, for example, from sucking the nipple or the thumb. Second, is the anal stage (1–3 years), where gratification is derived from gaining control over withholding or eliminating faeces. Everyday observations of toddlers highlight how, as they negotiate their increasing separateness from their parents, they come to view their faeces as their own possessions, which they want to give up or hold on to in their own good time. The potential for battles and conflict between parent and child, for instance, over toilet training, during this period is great. It is at this stage that defecation is said to symbolise giving and withholding. Metaphorically speaking, conflicts at the anal stage are seen to pose a major dilemma for all children with regard to the need to adapt to, or to resist, parental control.

The third stage (3–5 years), the phallic stage, sees the child beginning to be more aware of her genitals with consequent curiosity and anxiety about sexual differences. The phallic stage is thought to be particularly important to our psychological development because it is this stage that provides the backdrop to the Oedipal drama. In Greek mythology, Oedipus unknowingly kills his father and marries his mother. Likewise, according to Freud, all children during the phallic stage long to do away with the parent of the same sex and take sexual possession of the parent of the opposite sex. The notion of an Oedipal phase places desire at the core of our psychology.

The resolution of the Oedipus Complex is believed to be especially crucial to our development. Freud hypothesised that at the same time that the little boy harbours his incestuous desires towards his mother, he also experiences castration anxiety – the child’s fear that his father will punish him for his forbidden wishes by cutting off the guilty organ, his penis. Lacking penises, girls appear castrated to him and the little boy fears a similar fate. Girls, on the other hand, realising that they have been born unequipped with penises experience the female counterpart to castration anxiety, namely, penis envy. They are said to harbour angry feelings towards the mother for having created them without a penis. While the boy’s castration anxiety is what causes him to repress his longing for his mother, the girl’s penis envy is what impels her towards her father, desiring a child by the father-the desire for a chil...