54-2 What are the goals and techniques of psychoanalysis, and how have they been adapted in psychodynamic therapy?

The first major psychological therapy was Sigmund Freud’s psychoanalysis. Although few clinicians today practice therapy as Freud did, his work deserves discussion. It helped form the foundation for treating psychological disorders, partly by influencing modern therapists working from the psychodynamic perspective.

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Freud believed that in therapy, people could achieve healthier, less anxious living by releasing the energy they had previously devoted to id-ego-superego conflicts. Freud assumed that we do not fully know ourselves. There are threatening things that we seem to want not to know—that we disavow or deny. “We can have loving feelings and hateful feelings toward the same person,” notes Jonathan Shedler (2009), and “we can desire something and also fear it.” Psychoanalysis was Freud’s method of helping people to face such unwelcome facts.

Freud’s therapy aimed to bring patients’ repressed or disowned feelings into conscious awareness. By helping them reclaim their unconscious thoughts and feelings, and by giving them insight into the origins of their disorders, he aimed to help them reduce growth-impeding inner conflicts.

Psychoanalysis is historical reconstruction. Psychoanalytic theory emphasizes the power of childhood experiences to mold the adult. Thus, it aims to unearth one’s past in the hope of unmasking the present. After discarding hypnosis as an unreliable excavator, Freud turned to free association.

Imagine yourself as a patient using free association. You begin by relaxing, perhaps by lying on a couch. As the psychoanalyst sits out of your line of vision, you say aloud whatever comes to mind. At one moment, you’re relating a childhood memory. At another, you’re describing a dream or recent experience. It sounds easy, but soon you notice how often you edit your thoughts as you speak. You pause for a second before uttering an embarrassing thought. You omit what seems trivial, irrelevant, or shameful. Sometimes your mind goes blank or you find yourself unable to remember important details. You may joke or change the subject to something less threatening.

To the analyst, these mental blocks indicate resistance. They hint that anxiety lurks and you are defending against sensitive material. The analyst will note your resistances and then provide insight into their meaning. If offered at the right moment, this interpretation—of, say, your not wanting to talk about your mother—may illuminate the underlying wishes, feelings, and conflicts you are avoiding. The analyst may also offer an explanation of how this resistance fits with other pieces of your psychological puzzle, including those based on analysis of your dream content.

Over many such sessions, your relationship patterns surface in your interaction with your therapist. You may find yourself experiencing strong positive or negative feelings for your analyst. The analyst may suggest you are transferring feelings, such as feelings of dependency or mingled love and anger, that you experienced in earlier relationships with family members or other important people. By exposing such feelings, you may gain insight into your current relationships.

Relatively few North American therapists now offer traditional psychoanalysis. Much of its underlying theory is not supported by scientific research. Analysts’ interpretations cannot be proven or disproven. And psychoanalysis takes considerable time and money, often years of several sessions per week. Some of these problems have been addressed in the modern psychodynamic perspective that has evolved from psychoanalysis.

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Although influenced by Freud’s ideas, psychodynamic therapists don’t talk much about id, ego, and superego. Instead they try to help people understand their current symptoms. They focus on themes across important relationships, including childhood experiences and the therapist relationship. Rather than lying on a couch, out of the therapist’s line of vision, patients meet with their therapist face-to-face. These sessions take place once or twice a week (rather than several times per week), and often for only a few weeks or months.

In these sessions, patients gain perspective by exploring defended-against thoughts and feelings. Therapist David Shapiro (1999, p. 8) illustrates this with the case of a young man who had told women that he loved them, when he knew that he didn’t. His explanation: They expected it, so he said it. But with his wife, who wishes he would say that he loves her, he finds he “cannot” do that—“I don’t know why, but I can’t.”

Therapist: Do you mean, then, that if you could, you would like to?

Patient: Well, I don’t know…. Maybe I can’t say it because I’m not sure it’s true. Maybe I don’t love her.

Further interactions reveal that he can’t express real love because it would feel “mushy” and “soft” and therefore unmanly. He is “in conflict with himself, and he is cut off from the nature of that conflict.” Shapiro noted that with such patients, who are estranged from themselves, therapists using psychodynamic techniques “are in a position to introduce them to themselves. We can restore their awareness of their own wishes and feelings, and their awareness, as well, of their reactions against those wishes and feelings.”

Psychodynamic therapists may also help reveal past relationship troubles as the origin of current difficulties. Jonathan Shedler (2010a) recalls his patient Jeffrey’s complaints of difficulty getting along with his colleagues and wife, who saw him as hypercritical. Jeffrey then “began responding to me as if I were an unpredictable, angry adversary.” Shedler seized this opportunity to help Jeffrey recognize the relationship pattern, and its roots in the attacks and humiliation he experienced from his alcohol-abusing father—and to work through and let go of this defensive responding to people.

Interpersonal psychotherapy, a brief (12- to 16-session) variation of psychodynamic therapy, has effectively treated depression (Cuijpers, 2011; Markowitz & Weissman, 2012). Although interpersonal psychotherapy aims to help people gain insight into the roots of their difficulties, its goal is symptom relief in the here and now. Rather than focusing mostly on undoing past hurts and offering interpretations, the therapist concentrates primarily on current relationships and on helping people improve their relationship skills.

The case of Anna, a 34-year-old married professional, illustrates these goals. Five months after receiving a promotion, with accompanying increased responsibilities and longer hours, Anna experienced tensions with her husband over his wish for a second child. She began feeling depressed, had trouble sleeping, became irritable, and was gaining weight. A typical psychodynamic therapist might have helped Anna gain insight into her angry impulses and her defenses against anger. An interpersonal therapist would do the same, but would also engage her thinking on more immediate issues—how she could balance work and home, resolve the dispute with her husband, and express her emotions more effectively (Markowitz et al., 1998).

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