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