The Aim of Psychoanalytic Therapy

What is Psychoanalytic Therapy? – A Personal View, Part 8

The various mechanisms of unconscious conflicts and the ways they operate and stay concealed have never been better described and illuminated by anyone than they are by Freud. We have not been as good as he was at this and we still rely on his lucid descriptions of unconscious processes for making sense of what is going on in the mind.

No psychoanalytic therapist will endorse all Freud’s theoretical formulations, but no one has come close to offering as many thought-provoking suggestions as he did. Later developments by other writers in psychodynamic theory after Freud are either no more than small modifications and corrections to his work or, if they are radical (or if they have the appearance of being radical, like those of the French psychoanalyst Jacques Lacan for example) then they have not found the degree of acceptance enjoyed by Freud’s own work.

Every school and variant of psychoanalytic therapy has its own theoretical preferences, but if you have a good knowledge of Freud’s writings you will still be today more or less as up to date on the psychodynamic theory of the mind as anyone can be.
In contrast if you don’t know Freud’s work then, no matter what school of therapy you may nominally belong to, your knowledge of psychoanalytic theory will be to that extent superficial.

From a theoretical point of view, then, we are all of us – everyone in psychotherapy and counselling – still Freudians.

In contrast, where we have almost all departed significantly from Freud is in the application of his theory of the mind to the practice of therapy itself.

In this respect, contemporary psychoanalytic therapy has a different emphasis from the one Freud gave it.

The imperative of discovering the meaning unique to one’s life has infiltrated psychoanalytic therapy in many forms and guises apart from the “true self” suggested by Winnicott. Otto Rank, Carl Rogers, Viktor Frankl, Rollo May, Irving Yalom – these are just some of the most well-known of the many therapists and writers who, in the middle decades of the twentieth century, helped to re-orient psychoanalytic therapy in a direction closer to the one indicated by Nietzsche. And “becoming who you are” (the phrase originates with the Greek poet Pindar, circa 450BC) is now implicitly if not always explicitly the central aim of it. This is the most significant development that has occurred in psychoanalytic therapy since Freud.

This evolution has happened because it overcomes what was Freud’s most consequential deficiency as a theoretician of psychotherapy. This was his tendency to think of the curative process in therapy, primarily, as a going back somewhere, rather than as a going forward somewhere.

In his early work before 1900 he conceived the aim as being to recall the memory of a traumatic event that had been repressed from consciousness. Later on, as his insight developed, he thought of cure as the reconstitution of something within the mind that had become divided and dissociated, in other words the returning to consciousness of impulses or drives that had at some earlier time been repressed out of it.

Two points should be noted here. First, as a general statement Freud tended to think of cure in psychotherapy as depending on the restoration of a previous state of mind – especially the conscious mind – that had been lost at some time in the past. Second, he never showed any great theoretical interest in the process of therapy beyond that of the patient becoming aware of those things in his mind that had somehow got locked out of his consciousness.

Now clearly, whether or not a memory or an emotion can be accessed by consciousness is of the greatest importance. If I cannot get something into consciousness I cannot think about it in a critical way and without this I cannot deal with it in a therapeutic way. Freud exaggerates when he says, “We master all our impulses only by applying to them our highest mental functions that are attached to consciousness.” (“On Psychotherapy”, 1904, ERG 118) Most of our impulses after all are controlled unconsciously and we could not possibly be conscious, at least all the time, of everything in us that we have to control. Nevertheless, it does seem to be true that modifying our impulses and habits of necessity involves a complex process of dealing with them consciously before returning them to unconscious control.

However, just making things conscious is certainly not on its own a sufficient condition for achieving mental change or better health.

For example, I can have conscious awareness of a traumatic experience from my past, and of much of the emotions associated with that experience also, but this will not in itself be enough to give me freedom from the traumatic effects of that experience. Discussing such an experience in a dispassionate way with a therapist can be helpful. But if the trauma is a serious one, merely talking about it will not, on its own, be enough to overcome its effects.

I can understand in an intellectual way why I am depressed, anxious, or phobic. But unless there is also some emotional change in me, in addition to whatever intellectual insights I may achieve, I cannot say I have achieved a psychotherapeutic cure. In addition to intellectual work I have also to do emotional work.

Freud of course recognised this problem. His early solution to it, in his work before 1900, especially up to 1895, was that the patient had to “abreact” the emotions aroused by the memory of the traumatic experience that had initially caused the symptoms. This meant experiencing and demonstrating the affects associated with those emotions. This was the basis of the so-called “cathartic” cure, which preceded psychoanalysis in the proper sense of the word.

Soon however Freud came to believe that the real cause of the symptoms was not the traumatic experience as such, and therefore not the repression of the experience out of memory, but rather the conflict between the drives provoked or intensified by the traumatic experience. This meant that the process of cure was going to be more complicated than simply experiencing a repressed emotion. Cure was now going to have to involve not just the subjective experiencing of emotions, but the reconciliation of emotions that are at odds with each other.

Consciously experiencing rage for instance towards someone who has abused me as a child is more psychologically honest, and more healthy, than not experiencing such rage. But, by itself, this won’t take me past the conflicts in myself that have been provoked by the abuse. It won’t, for example, deal with the deeper problem of emotional dependence on an abuser that can often arise on the part of a victim.

Freud believed the answer to this problem of reconciling conflicting emotions was for the patient to become aware of how these repressed conflicts were playing themselves out in the relationship with the therapist. As long as they were still doing so he referred to this as the transference relationship, because the patient is transferring feelings into the relationship with the therapist that originate in earlier relationships.

When the patient became aware of how these emotional conflicts from the past were active in the present, and healed them by outgrowing them, the transference was said to be resolved. At this point, for Freud and for many of his contemporary pupils, the therapy was thought of as being at an end.

Clearly, developing a relationship with my therapist that is realistic and not dominated by unacknowledged motives in myself has to be an essential part of any successful therapeutic process.

Nevertheless the truth is that until I have found a way of turning understanding of myself into a practical basis for overcoming my problems and making something new out of my life as a whole, then my psychotherapy is not complete.

I have to find ways to integrate the new awareness I acquire through the dialogue with my therapist into the rest of my life. I have to discover ways to turn what have up to now been obstacles in my path into opportunities for development.

Nowadays we think of the process of cure much less as the restoring of some past mental condition, as Freud did, and much more as the moving forward to a new level of development, as Nietzsche did. We think of the self not as something deeply buried waiting to be excavated – Freud loved archaeological analogies for the work of psychoanalysis – but as something transcendent, waiting to be achieved. This implies the development and integration of things in the mind that have not yet found a way of being reconciled to each other.

This is why the idea of re-creating oneself, shaping oneself, giving renewed meaning to one’s life, has become such an important one in contemporary psychoanalytic therapy and in psychotherapy generally. The self is not something we remember, nor is it something we reconstitute, it is something we have to make, and go on re-making over and over again.

This shift of aim in psychoanalytic therapy from the excavation of things that already exist buried in the mind to the evolution of things that the mind can as yet only partly imagine has also changed our expectations of the course that therapy will take over time.

Initially, for Freud’s contemporaries and well up to the 1950s and 1960s, psychoanalysis was expected to be very time-intensive, involving perhaps as many as five sessions in a week, but of definite overall duration, in the early days when Freud was working pretty much alone, perhaps six months at maximum.

Later on, by the time of The First World War for instance, Freud made no bones about treating patients sometimes for several years. But however the length of the psychoanalysis was conceived, there was assumed to be, for most analyses, some fairly clear ending point. This was the point at which, in a successful therapy, it was assumed the patient would have brought into consciousness everything of significance that had been previously hidden in his unconscious. He would have restored everything that had previously been lost to his conscious mind.

In these former days it was common to hear a patient of psychoanalysis described as “needing more analysis” or on the contrary as “not needing more analysis”, as if there were a clear finish line somewhere that had or had not been reached by the therapy.

Apart from a few die-hard traditionalists few people in the world of psychoanalytic therapy talk in these terms any more. By the 1930s, the last decade of his life, Freud himself had become openly sceptical of a clear ending point for analysis; in fact he had come more and more to think of psychoanalysis as essentially a means to greater self-knowledge, and not primarily as a medical cure for illness. (See, for example, his late essay of 1937, Analysis Terminable and Interminable). This was also another reason why he insisted that the practice of psychoanalysis should not be confined to those with a medical training. (See On the Question of Lay Analysis, 1926)

Nowadays, we expect therapy to be less intensive, anything from once or twice a week, at one end of the scale, to once or twice a month, at the other. Concomitantly, we expect the overall course of therapy to last much longer: several years is typical. This reflects the fact that the final aim of therapy is now thought of as maturation and development, things which by definition require the duration of time, and to which, in a healthy individual, there is no clear point of conclusion.

This change in objective for psychoanalytic therapy has also meant a change in the place we attribute in the therapy to the relationship between therapist and client. Freud spoke of this transference relation as an “artificial neurosis”, created by the conditions of the therapy itself. The therapy was considered properly over when this artificial neurosis came to an end. Now we think instead of the relationship between therapist and client primarily as a therapeutic alliance and as a catalyst for development in the rest of the client’s life.

In parallel with this development in our conception of the aim of therapy we have also seen a significant shift in the concept of mental illness.

At the end of the nineteenth century neurosis was almost always seen as reflecting some weakness or deficiency in the person. Our judgement now on this is much more nuanced. Once again, it is closer to that of Nietzsche who often stresses the debt he feels he owes to illness of one sort or another for giving him insights into life that he would not otherwise have reached.

The capacity for development is a sign of vitality and as Nietzsche points out this may also include the capacity to develop the “illnesses” and emotional symptoms that force us to develop. The potential for suffering from emotional conflict is itself an indication of a capacity for a deeper awareness of the complex realities of human life. A human being who has never wrestled with a difficult dilemma is one who has not experienced his full emotional potential.

This is why to describe people who seek therapy as being “sick” and in need of a “cure” has become problematical. Every therapist is aware that the person who becomes his client is more often than not the only one in the family constellation who is strong enough to think critically about his own motives and development. This is another reason why psychotherapy has more and more ceased to be seen as an adjunct of medical science, where, in contrast, the distinction between being sick and being healthy is rarely a difficult one to make.

Tomorrow: (9) Psychotherapy and The Question of Meaning

The Notion of “The True Self” in Psychoanalytic Therapy

What is Psychoanalytic Therapy? – A Personal View, Part 7

Apart from displacement, among the other important themes that Nietzsche introduces into modern thought that have become indispensable to psychotherapy is the emphasis on the need to give shape to one’s own life, rather than relying on values inherited from religion and traditional morality to give this to us.

This ethical ideal of self-formation is the counterpart to the ending of the traditional moral opposition between self-interest and altruism implied by the discovery of psychological displacement. If goodness in a human being can no longer be defined simply as altruism and self-sacrifice then it has to be considered in a new way. It would be false to say that at the moment we do have an alternative notion of goodness that enjoys broad consensus. The awareness of this absence is in many ways what defines modernity. Nevertheless, the idea of goodness in a human being is now difficult to sustain if it does not include an honesty with oneself about one’s own motives, and some capacity to learn, develop and reshape one’s aims in life.

This imperative of discovering and re-discovering what are the priorities unique to one’s life, and seeing this as the answer to the suffering of life, is implicit in Freud’s work, and also in his own life, which was distinguished by personal courage, creativity, and re-invention of the self in the face of crisis. But it does not receive formal stress in his theoretical writing.

It has however come to be an indispensable one for psychoanalysts and psychoanalytic therapists since Freud.

For instance, in the 1960s the psychoanalyst Donald Winnicott (1896-1971) spoke of a distinction between what he called the “false self” and the “true self”, terms that are not to be found in the writings of Freud. (Cf. “The Concept of the False Self”, 1964, reprinted in Home Is Where We Start From, Penguin, 1986, pp. 65-70)

As Winnicott acknowledged, such a distinction is anything but new. The general idea is also not hard to identify in many of Winnicott’s predecessors and contemporaries in psychotherapy, including Otto Rank, Carl Rogers, who spoke of the “real self”, and Karen Horney.

In fact the idea can be traced back through the centuries in the works of countless philosophers, seers and moral teachers. “What does it profit a man if he gain the world and lose his own soul?” asks Jesus (Mark 8:36), rhetorically indicating the perennial problem that what our true self really needs is not necessarily what the rest of the world thinks it needs. “I am who I am,” says the Lord of The Old Testament (Exodus 3:14) when Moses asks who is commanding him to lead his people in a dangerous revolt against the power of the Egyptian state. This emphasis on the unprecedented, that is to say, unnameable, nature of any act that proceeds from the true self is echoed by Shakespeare when he has Romeo reply to Juliet’s question who he is, “By name I know not how to tell thee who I am.” (Romeo & Juliet, II.2.54-5) In Greek thought, Plato’s theory of Forms assumes the truth of what we are is something that has to be discovered behind the surface of appearances. The assumption that what is true about us and what is apparent about us are two different things is possibly the oldest assumption of Western culture, and perhaps of all culture.

In his discussion of “the true self” Winnicott refers to the famous remark of Shakespeare’s Polonius in Hamlet, dating from 1600, “To thine own self be true,” and suggests that Shakespeare gives these lines to what he calls “a crashing bore”, in order “perhaps to avoid being smug”. (ibid.)

But Shakespeare’s aim here is deeper than this. In giving the expression to a character who so signally lacks self-awareness and a knowledge of what his true self is, a “foolish prating knave”, as Hamlet calls him (III, 4), Shakespeare draws our attention to how easily the idea of the “true self” can be emptied of meaning. The point is that Polonius has never doubted that he knows what his “true self” is. The result is that, coming from such a man, because there is no genuine thought behind them, the words “to thine own self be true” become an instant cliché.

And in a culture such as ours, even more than in 1600, where “being true to oneself” is endlessly repeated as if it were the easiest thing in the world, the danger is that it simply degenerates into another advertising slogan. This is highlighted with comical irony in the film Clueless. Here, Cher, the kind-hearted teenager who is also almost entirely a victim of fashion, is nevertheless the only one among her friends to remember that the phrase “to thine own self be true” is not actually uttered by Hamlet himself, the character in literature who epitomises, if any does, the search for the reality of man underneath the ephemeral surface, but on the contrary, as she points out, by “that Polonius guy”.

In giving the phrase to the superficial courtier Polonius, and not to the tormented philosopher Hamlet, Shakespeare is, as ever, underlining how deceptive language can be and therefore how vital it is to observe what a man is doing and not to get distracted by what he says he is doing. We readily respond to words as substitutes for the things they conventionally represent, and mistake the expression of a word for a real commitment to achieving the thing it denotes. Polonius is the archetype of the politician, and, sadly, also too many psychotherapists and counsellors: hearing himself using words for a widely approved objective, he tries to persuade others, and more importantly himself, that this is what actually motivates him.

Shakespeare uses the character of Polonius to illustrate the mistaken but perennial assumption that the true self is something that can be easily known. The famous opening line of Hamlet is, “Who’s there?”, and at an important level the whole play is a meditation on the question of what identity is. Who and what exactly is the true self? The answer is, it’s very hard to know and we never know for sure.

Our age, however, like the age of Polonius, and like every age, does not want to acknowledge this. We defend ourselves against the difficult challenge of discovering the true self by pretending to ourselves that we already know what it is, or that there is some reliable formula that is guaranteed to discover it for us.

Freud reflected deeply on Hamlet (see his famous analysis of the play, alongside that of Sophocles’ Oedipus, in The Interpretation of Dreams). And the question, “Who’s there?” could as easily be taken as a maxim for psychoanalytic therapy as a whole. The most important assumption underlying psychoanalytic therapy is that we do not know who’s there until we are prepared to undertake the difficult and sometimes disturbing work needed to find out. It requires effort and it requires courage. As Freud pointed out, we resist knowing who’s there because we have strong and hidden motives for not knowing who’s there. For Freud, overcoming this resistance was the most difficult and the most important part of psychotherapy.

We need to be aware that there are however two distinct ideas of the true self in the history of psychoanalytic therapy and in psychotherapy generally, although they are intimately connected with each other.

The first is the one that is implicit throughout Freud’s work. This comprises the existing impulses and feelings that we are reluctant to acknowledge consciously. We are reluctant to do this because we feel they are unworthy of the kind of person we would like to think we are, or because we feel others on whom we depend would condemn us for having them, or because we feel they are unacceptable for some other reason.

The second one is the future self that Nature intends us to develop into and become. This is the one that Nietzsche, the philosopher and secular prophet, emphasises, in a way that Freud, the sober medical man, does not.

In his early essay of 1874, for instance, on Schopenhauer as Educator, Nietzsche remarks, “your true self [dein wahres Wesen] is immeasurably high above you”. [152] Finding our true selves, in other words, is the work of a lifetime. It is not something we stumble upon one day and then possess for the rest of our lives, it is something we have to spend our lives creating and building.

This perspective on the self as inherently transcendent, as something that does not exist until we create it, and is never completed, continues all the way through Nietzsche’s work. It is the kernel of his famous idea of the Übermensch; this is simply a word for the individual who strives to confront him- or herself with honesty and to overcome that within the self which remains fixated on the injuries of life, using these as an excuse not to develop. The idea is expressed again in the epigraph of Nietzsche’s last, posthumous work, his autobiography, Ecce Homo: “How one becomes what one is [Wie man wird, was man ist]”.

And it is the true self in this second, prospective, sense that Winnicott somewhat gingerly introduces into psychoanalysis in twentieth mid-century. In doing so Winnicott does not mention Nietzsche. But it is clear he is referring to this idea of discovering the meaning that is unique to one’s life, and he is suggesting this as, ultimately, the best response we can make to the emotional distress that being human inevitably entails. Winnicott is in effect proposing the development of the “true self” as the proper aim of psychoanalytic therapy. And in large measure, this is what it has become. This is the overarching value that justifies psychoanalytic therapy.

Tomorrow: (8) The Aim of Psychoanalytic Therapy

The Intellectual Roots of Psychoanalytic Therapy: Nietzsche and The Theory of Displacement

What is Psychoanalytic Therapy? – A Personal View, Part 6

Freud’s development of psychoanalysis did not happen in a vacuum. He drew for inspiration on a wide range of predecessors in 19th century medicine, psychology and philosophy, as well as the great dramatists, poets and novelists of the past. As he himself was the first to acknowledge, the idea of the unconscious mind, the idea of unconscious conflict, the idea of defence against unpleasant and disturbing thoughts leading to their repression from consciousness, the idea of infantile sexuality, and other ideas that characterise psychoanalysis, had all been anticipated in one form or another before him. Freud’s importance is not that he was the first to think of any of these ideas but that he was the first to combine them together to create a viable form of psychotherapy.

As it has developed after Freud, modern psychotherapy has followed Freud’s example by continuing to draw inspiration from these older, pre-Freudian sources.

The philosopher and psychologist who is the most important anticipator of Freud’s thinking and who is closest to him in intellectual spirit is Friedrich Nietzsche (1844-1900). Nietzsche has had a deep impact on many areas of modern thought. His influence on the development of psychotherapy in particular, though not always acknowledged, has been profound. Freud once called him the first psychoanalyst.

When Freud was developing psychoanalysis in Vienna at the end of the nineteenth century he was working in an intellectual environment where there was widespread discussion of Nietzsche’s ideas. Though he was too ill to write any more after 1890, and died in 1900, during this period Nietzsche became an inspiration to the modernist intellectual movement that emerged throughout Europe in the years before the First World War.

Modernism has many strands in the humanities and sciences and in the arts and literature. It is characterised by an awareness that the religion and morality that guided European civilisation for centuries has burnt itself out, and that modern culture will be dominated by the ideals of science, technology and rationalisation, but that these developing trends will nevertheless collide and interact with, and at the same time come to reflect, the underlying irrational nature of human beings.

Joyce, Proust, Mann, Kafka are representatives of this modernist sensibility in literature; Mahler is in music; Munch is in the graphic arts; Max Weber is in social science. And there are countless other pivotal figures that could be mentioned here. Psychoanalysis is another part of this modernist movement, a movement that continues to shape all our thinking in the arts and humanities today.

Freud said he refrained from reading Nietzsche too closely because he wanted to develop his ideas as independently and as much in the light of his own clinical experience as he could. But there is no doubt he was influenced by this atmosphere of discussion of Nietzsche’s ideas. As a medical student he also had a friend, Joseph Paneth, who had met Nietzsche, and who discussed his ideas with Freud. [cf Ronald Lehrer, Nietzsche’s Presence in Freud’s Life and Thought, 1995, pp.44-51] And many of those who later became Freud’s followers, including those who subsequently broke with him to form their own schools, like Alfred Adler, Carl Jung and Otto Rank, made no secret of how important Nietzsche was to their own thinking. After Freud himself, Nietzsche is much the most significant shaper of the contemporary world of psychotherapy.

Nietzsche was especially interested in the psychology of religion and morality and in uncovering the unconscious roots of the emotions associated with these things. This is where his strengths are to be found, just as Freud’s are in the psychology of the family and of childhood and of sexuality.

Nietzsche is, in particular, the first thinker systematically to explore the notion of unconscious displacement. Displacement refers to the shifting of an emotion from the person it was originally aroused by and directed towards, through symbolic connections and associations, and as the result of conflict with other emotions and interests, onto a different person.

For instance, Nietzsche was the first psychologist to trace clearly the psychological mechanisms behind masochism, the inflicting of suffering on the self, making plain that it is a displaced form of sadism, the inflicting of suffering on someone else. Masochism can be as gratifying as sadism to the subject’s wish for cruelty, in fact it may be more gratifying; all that happens, from a psychological point of view, is that the self has been substituted for some other person as the object of the sadistic emotion. Masochism is accompanied by the unconscious thought, “I cannot make him suffer, but I can make myself suffer, and make him watch my suffering and feel uncomfortable and guilty because of it. I may also be able to stir up the anger of others, more powerful than me, towards him, through their identification with my displayed distress.”

An important point stressed by Nietzsche is that masochistic behaviour towards the self is every bit as much a reflection of self-assertion as is sadism towards another. Try as we may to evade it, egotism, the assertion of the interests of the self, animate everything we do.

Along with this insight into masochism and sacrifice of the self goes of course the corollary that caring for others, looking after them, tending them, healing them, protecting them, and so forth, may be, through identification with them, a displaced way of caring for ourselves. At the same time, caring for others can also, through the exercise of greater control over ourselves, be a displaced and sublimated way of gratifying our wish for power over them.

Nietzsche points out that our sense of identity is never clear-cut and precise, and that we identify one person with another person, and ourselves with others, and others with ourselves. As a result of this we can never be completely certain about where our most powerful emotions and feelings are directed. Love of others is always entangled with love of ourselves; hatred of others always goes hand in hand with hatred of ourselves.

These are revolutionary insights, because they undercut the ancient assumption (it can be traced back at least as far as Plato’s Republic in circa 400BC) that there is a fundamental moral difference between caring for someone else and caring for oneself, and between hurting oneself and hurting someone else, and therefore that the basis of morality is putting the interests of others ahead of one’s own.

In overturning this assumption Nietzsche lays the foundation for modern psychotherapy. Psychotherapy in the contemporary sense is only possible in a moral world in which the care of the self is regarded as being at least as important, and sometimes more important, than care for others. The idea that our moral duty to others can be isolated from our moral duty to ourselves is simply no longer tenable. To neglect ourselves is to neglect others, and to neglect others is to neglect ourselves. We are rediscovering here the ancient wisdom of the Jewish talmudist Hillel (circa 50BC) who famously remarked: “If I am not for myself who will be; and if I am for myself alone, what am I?”

If we had to identify the single most important insight in psychoanalytic therapy, and in the whole of modern psychotherapy and counselling, it would be this mechanism of unconscious displacement. In psychoanalytic therapy we are considering all the time how we shift our attitudes and feelings from one person to another, and from other people onto ourselves, and from ourselves onto other people.

This is how, for instance, we transfer our feelings that originate in our relations with our parents onto our adult partners, and onto our children. It is how our love and our anger get turned on people who apparently have had no objective role in provoking such emotions, how we come to persecute other people because they reflect things we don’t like in ourselves, and how we come to punish ourselves for things that were done by other people. This mechanism of displacement is the key to understanding the universe of irrationality that characterises human life and action.

The displacement of emotions plays such an extensive part in human life because we live so much by symbols and metaphors. This is another way of saying that, more than any other animal, we experience one thing as like or similar to, or associated with, or a substitute for, another thing. This makes us a very creative animal but it also amplifies, to an extent that is unparalleled in the rest of the animal world, the scope for both conscious and unconscious conflicts between our wishes, impulses and drives. Our wishes are continually getting entangled in each other, trying to achieve objectives that they feel are like an objective they cannot reach, and in the process forming alliances with each other, and at the same time pursuing aims that are incompatible with those of others.

It is because it takes the part played by symbolism and metaphor in human life so seriously that psychoanalytic theory has consistently outperformed in sheer fruitfulness every other model for human psychology that we have seen. These other models, invariably, have tried to mimic the sciences of other things, especially the psychology of others animals. But in doing so they have let slip from their grasp the essence of what makes us human.

Tomorrow: (7) The Notion of “The True Self” in Psychoanalytic Therapy

Psychoanalytic Therapy is a Psychodynamic Therapy

What is Psychoanalytic Therapy? – A Personal View, Part 5

The second distinguishing characteristic of psychoanalytic therapy, after its rooting of the symptoms of emotional distress in the history of our personal lives, is that it considers the human mind as a place of conflicts between different wishes and drives, and it treats the symptoms of emotional suffering as expressions of these underlying conflicts.

Life all the time presents us with painful choices and dilemmas. For instance, we often feel we should behave in a caring and considerate way towards people whose behaviour may be hurting or injuring or confining us.

To return to our previous example, a man might feel under an obligation to care for his ailing mother, even if he has himself never received much genuine love from her. He might spend years looking after a difficult, selfish woman for whom he feels little real affection. And the price he may pay for this is having to put on hold the development of relations that are important to his own long-term wellbeing.

In dilemmas like this, which arise in one form or another all the time in life, discovering just where is the correct balance between doing our duty to a parent, or a partner, or a child, and fulfilling our duty to ourselves, can be very difficult.

The emotional conflicts produced by this kind of problem are not trivial; often they make people anxious and depressed, and they can cause physical illnesses in addition.

Freud was very skilled at tracing the different ways in which we can get caught in personal conflicts like this. Such conflicts often take unexpected forms, or forms that we do not like to acknowledge. Freud said that we, in his term, defend ourselves against acknowledging many such conflicts in ourselves, because we feel ashamed of some of the impulses in ourselves that generate them, and we don’t know how to resolve them. When we defend ourselves against conflicts like this they are said to be repressed out of our conscious awareness. Freud regarded overcoming this defence as the main aim of psychotherapy. He believed the most important thing in life is to have the courage to face the truth about our real motives. All modern forms of psychotherapy that place an emphasis on being honest with ourselves show Freud’s influence.

Because it is focused on personal conflicts like these between emotions, we say psychoanalytic therapy is concerned with the dynamics of the mind. For this reason psychoanalytic therapy is often also referred to as psychodynamic therapy. These two terms mean the same thing.

Tomorrow: (6) The Intellectual Roots of Psychotherapy: Nietzsche and The Theory of Displacement

Psychoanalysis and Psychoanalytic Therapy

On the relation between Psychoanalysis and Psychoanalytic Therapy

What is Psychoanalytic Therapy? – A Personal View, Part 4

Freud’s therapeutic work and his writings are correctly described as psychoanalysis, because this is the term he coined for them. The first one or two generations of his adherents and followers are also rightly described in the history books as psychoanalysts. This is what Freud called them, unless they made a formal break with him, as some of them did, and it is what they called themselves.

Some psychotherapists today still call themselves psychoanalysts. But it is now over 80 years since Freud’s death and if the term psychoanalysis is today intended to mean a psychotherapy that is shaped exclusively by the ideas and practice of Freud, such a thing no longer exists. Everyone who now calls himself a psychoanalyst is, in practice, implementing a form of therapy that is influenced by Freud and also by other people in addition to Freud. In other words, he is practicing a form of psychotherapy that can be accurately described as more, or less, psychoanalytic.

For this reason many psychotherapists like myself who acknowledge a major debt to Freud’s work, but who wish to emphasise at the same time that other influences are also important to their idea of therapy, call themselves simply psychoanalytic therapists.

In cutting our way through the jungle of terms that has come to plague the contemporary field of psychotherapy, the attempt to draw a distinction between psychoanalysis and psychoanalytic therapy is no longer of value. From the point of view of a member of the general public trying to figure out what kind of therapy he can expect from a given practitioner, psychoanalysis and psychoanalytic therapy may be treated as the same thing. Some therapists using these terms will try to adhere more closely to a model of therapy associated with Freud, and others will be less concerned with this. But until you meet the therapist you will not be able to tell from the title he chooses what is his practice in this regard. Except when referring specifically to historical events and the development of psychotherapy in the past, I shall therefore for the remainder of this essay ignore any distinction between the two terms.

The most important distinguishing characteristic of psychoanalytic therapy is that it places emphasis on treating emotional problems by looking at the biography of the person as a whole. The symptoms of the individual are taken to be the outcome of his whole history, development and life circumstances.

One of the words that regularly occurs in Freud’s writing is context – Zusammenhang, in German. Freud is looking for contexts within which the symptoms of the patient make sense. In other words, he is looking for connections within which the symptoms form part of a comprehensible story. What this means in practice is that we connect symptoms with events and experiences in the individual’s life by postulating emotions and motives that plausibly link them.

For example, if a young man falls physically ill with chronic debilitation, headaches and vomiting, and it emerges that he has spent the last several years caring for a mother who has been suffering from a terminal illness, then it is possible he has fallen ill, at least in part, because he has had to deal for so long with the conflicts between his feelings that have arisen as a result of such a demanding way of life.

Furthermore, if, when we speak in confidence to the man, he tells us he has had to postpone for some years his marriage to his fiancée, then we may have further reason for believing the man’s physical symptoms are in part at least a reflection of the stress he has experienced. His symptoms, in other words, are the way that the emotions he may have not been able to admit to himself, or convey to his mother, have found to express themselves.

Freud writes, in Studies On Hysteria, from 1895:

I am struck by the fact that the case histories I write read like short stories and that they dispense with what one might call the serious stamp of the scientific … However, a searching presentation of the mental processes that one is used to getting from the creative writer permits me, with the application of a few psychological formulas, to achieve a degree of insight into the development of a hysterical illness. [SH 131]

The work that Freud regarded as his most original and significant contribution was his book on dreams. This he entitled the Interpretation [Deutung] of Dreams, rather than the Explanation [Erklärung] of Dreams. Psychoanalytic therapy, and this is true of psychotherapy and counselling in general, is an interpretive discipline, we are concerned with the meaning of symptoms. And “meaning” here refers to the connections that a symptom has with the lived experiences, intentions, concerns, anxieties, hopes and aspirations of the patient.

This is why narrative is such an important part of psychotherapy. We treat symptoms by making stories that make sense of them. And, surprisingly enough, because we are creatures who live so much by stories, making good narratives out of our emotional problems has a powerful therapeutic effect on them.

What the work of psychotherapy reveals to us is that removing symptoms often turns out in practice to be less urgent a matter than discovering what is their meaning in the narrative flow of our lives. It turns out that we develop emotional symptoms not, as with symptoms arising out of our physical nature, because something has gone wrong in our make-up, but because something has happened to us whose meaning we need to find out. The emotional symptoms we develop are a way of forcing us to find this meaning. In other words, unlike physical symptoms which arise because we are not well, emotional symptoms arise as an adaptive, and ultimately creative, measure for dealing with life itself.

Doctors and psychiatrists tend to disregard perspectives like this, or at best they regard them as outside their sphere. In the main, they want to treat our emotional symptoms as if they were of the same nature as our physical symptoms, that is, as signs of an underlying system failure that needs to be repaired. But this approach, although it certainly has its place in treating emotional problems, especially those that are clearly rooted in neurological malfunction, is much less helpful in addressing those of our symptoms that we develop in the course of the battle of life itself.

Freud had a lot of experience in the medical science of his own day and though he insisted that psychoanalysis was a part of science, he was not afraid to propose accounts of things that did not look the way medical science was expected to look. Freud understood, in a way that many of his critics down through the years have not, that the shape a science takes will depend on the thing it is studying.

In 1925 looking back on his development of psychoanalysis at the turn of the century, Freud wrote: “Even the psychiatrists, to whose attention came the most unusual and surprising mental phenomena, showed no inclination to examine their details and trace their contexts. They were satisfied with classifying the variety of the manifestations of illnesses and where possible with tracing them back to sources in somatic, anatomical or chemical disturbances. In this materialist or better mechanistic period medicine made great advances, but it also overlooked in a short-sighted way the most important and difficult of the problems of life.” [The Resistances against Psychoanalysis, 1925, SD 227]

Nothing could be more mistaken than the idea that Freud was trying to force the science of the mind into the pattern of a science designed for something else, like biological evolution, or physics. Yet this is what Freud’s critics – and indeed many prominent psychoanalysts also – have often claimed. For a relatively early example of this argument, out of scores of other works that could be cited, see Thomas Szasz’ famous The Myth of Mental Illness, first published in 1961. Szasz argues, rightly, that psychotherapy is an essentially interpretive discipline, rather than a medical discipline. And this is why he asserts that mental “illness” is a “myth”. But he asserts, quite wrongly, that Freud saw psychoanalysis as an application of the physical sciences that underlie medicine.

On the contrary, it is plain to anyone who takes the trouble to read him that trying to force the human mind into a scientific medical straight-jacket is exactly what Freud was not doing. Indeed this is exactly why he was so successful, where almost everyone else who attempted to develop a science of the mind ran into the sand. What he was doing was using some of the expressions of the physical and biological sciences as symbols and metaphors for mental processes. I have looked at the precedents for this in the classical German literature in which Freud was steeped in my own study, The Last Resistance, from 2002.

As Philip Rieff remarks, “Far from being a residual idea left over from his biological training, as the neo-Freudians have maintained, Freud’s theory of instinct is the basis for his insight into the painful snare of contradiction in which nature & culture, individual & society, are forever fixed.” (Freud: The Mind of the Moralist, The University of Chicago Press, 1959, Third Edition 1979, pp. 33-34)

This is exactly right. Many people both inside and outside psychoanalysis have encouraged us to jettison the metaphors Freud employs from the biological and physical sciences, on the assumption that some kind of purer or clearer discipline will result. But without these metaphors psychoanalysis is impoverished because we start to lose sight of precisely the kind of inescapable conflicts that Freud draws to our attention.

We may with as much justification regard a careful analysis of someone’s unconscious motives as scientific as we may, for instance, a careful piece of historical, biographical, social, or legal, research. All investigation like this, when it is properly conducted, involves a mixture of close attention to the empirical evidence, and the development of hypotheses that describe human motives.

But to expect the science that develops from this kind of analysis to look like physics, or animal ethology, or to regard it as a failure because it does not look like these disciplines, is purely superstition. There is more to science than the physical and animal sciences.

At the same time, one must be careful not to fall into the opposite error, which is even more widespread, of thinking that the sciences of human life are in some radical way disjoined from the physical sciences and involve some entirely different logic and reasoning. We must acknowledge the unusual place of the human mind in nature, while also recognising that its place is in nature. It was Freud’s success in doing just this that explains the continuing fecundity of his ideas.

But not everyone has been able to maintain this difficult balance. In the middle decades of the twentieth century, for instance, the medical psychiatrists of the United States embraced psychoanalysis with an enthusiasm that reflected a mistaken understanding of its true nature. In the years after World War II a training in psychoanalysis was a pre-requisite for any career in American medical psychiatry and no one was allowed to practice psychoanalysis who did not have medical qualification. What these doctors failed to see, for some decades, was that psychoanalysis could not be integrated with the rest of their medical training, because it represents a different kind of intellectual discipline. When this truth finally did dawn, particularly in the 1970s and 1980s, they abandoned it entirely, as if it had failed to keep some promise ti had made to them. Nowadays any American psychiatrist who has an interest or training in psychoanalysis and who hopes to make any kind of career will keep this quiet. And in general on this side of the Atlantic also, people with a medical training and background now no longer play any major part in the world of psychotherapy.

Tomorrow: Part 5: Psychoanalytic therapy is a psychodynamic therapy