ABSTRACT | PDF

Seminar III

Psychoanalysis

Pranjal Sharma

Postgraduate Trainee of Psychiatry, Silchar Medical College and Hospital

Introduction Psychoanalysis has existed since before the turn of the century and in that span of years has established as one of the fundamental disciplines within psychiatry. It is a theory that in many ways remains the most comprehensive and most profound understanding of human behaviour and experience. Despite the ferment of new discoveries, the breaking of new grounds in the exploration of psychopathology, psychoanalytic theories remain the bedrock of psychodynamic understanding. Psychoanalytic concepts have so widely permeated the training and practice of modern psychiatry that they have come to be regarded as a fundamental part of the understanding and approach to mental and emotional disorders. One cannot therefore overstate the importance of a clear understanding of psychoanalytic theory in an approach to mental illness and particularly an understanding of the basic contributions of the founder of psychoanalysis, Sigmund Freud.

History and evolution Psychoanalysis is the child of Freud’s genius. Formative influences on Freud’s thinking and on his development stemmed from various sources. During the period of his medical apprenticeship in the Helmholtz school of medicine, Darwin and his associates in biology, physiology, and physical investigations were producing a new and vigorous scientific climate. During this period, Freud worked in the physiological lab of Ernest Brucke, a leading founder of Helmholtz school of medicine. This school postulated that “all biological organisms are to be counted as a physical system. They are composed of a system of atoms governed by physical forces according to the principle of conservation of energy” (Robert Meyer 1842).

Freud was strongly influenced by these basic principles and even more by Brucke himself. Brucke’s basic presumption was that the mind and the body are organised along the principle of psychophysical parallelism. This assumption allowed him to describe mental processes partly in physical and partly in psychological terms. Brucke declared that the model of neural functioning is the reflex arc that is the whole nervous system functions as a more or less passive instrument that remains at a state of rest until it is stimulated by exogenous energies and that the system is activated in such a way as to reduce the incoming irritation to a minimum.

In 1882 Freud though inspired by Brucke’s ideology had to quit his lab because of financial considerations and begin to work as a general physician in Vienna General Hospital. In 1885 he received a coveted travelling grant that allowed him to visit Paris where he studied for about 19 weeks under the great French neurologist Jean Martin Charcot in Salpetrier, the famous French hospital. Under Charcot’s influence he became deeply interested in the problem of hysteria and found that the views that Charcot had regarding hysteria were very much divergent from what was in Vienna.

Charcot recognised hysteria as a legitimate disease of nervous system and one worthy of scientific enquiry. The possibility that hysterical phenomenon might be psychological in origin was suggested to Freud by the fact that Charcot was able to reproduce hysterical paralysis, seizure through the use of hypnotic suggestions. It was probably under the influence of Charcot that Freud began to suspect the connection between hysterical pathology and sexuality. Charcot even referred to hysteria as “Une Chose Genitalis”.  The use of hypnosis in the study of hysteria which Freud had become familiar with in Charcot clinic was to provide one of the most significant point of origin of psychoanalysis. In a sense it can be said that psychoanalysis has its basic roots in hypnosis and that Freud’s application of hypnosis in the study of his hysterical patients set his feet on the path of psychoanalytic discovery.

In 1886, Freud returned to Vienna, devoted himself with translation of works of Charcot and published a paper in 1891 entitled “Aphasia” where he formulated that symptoms were unrelated to anatomical lesion but reflected pattern of meaning and symbols related to associated networks. Freud thereafter conceived the scheme of elaborating a complete psychology that would be based on the phycalistic suppositions of Helmholtz’s school. For nearly 2 years (1895-1897) he struggled with this idea and thereafter wrote his “Project for a scientific psychology”. But because of difficulty in establishing a definite relationship he became discouraged and finally gave up the “Project”. During all this time he was working with Breuer on the problem of hysteria and in 1893 published “Preliminary Communications” and in 1895 “studies on hysteria” and finally in 1900 “Interpretation of Dreams”. In all this he extended Charcot’s concept of traumatic hysteria that symptoms were thought to be related to some psychic traumata sometimes clearly and directly and sometimes symbolic and that were not followed by   sufficient emotional reaction and thus kept out of consciousness.

On this basis Freud reconstructed the following: patient undergoes a traumatic experience. The idea is incompatible with the dominant mass of consciousness, the ego. Therefore intentionally dissociates or represses from the consciousness. Excitation associated with incompatible ideas was converted to somatic pathways. If traumatic experiences can be brought to consciousness and reacted with sufficient affect, symptoms disappeared.

In the beginning he used hypnosis or hypnotic suggestions to relieve symptoms of hysteria. But soon he found that the relief was transitory and seemed to be effective as long as the patient remained in contact with the physician and he began to feel that alleviation of symptoms was actually dependent on some manner of personal relationship between patient and physician which he later identified as “transference”. He also discovered that many of his patients were refractory to hypnosis and gradually recognised that his inability to hypnotise certain patients might be due to patients’ reluctance to remember the traumatic events which he later identified as “resistance”. He therefore felt the need to develop an approach to treat and that could successfully be applied regardless of whether the patient is hypnotisable or not. This led to the development of the “Concentration Method” a modification of the technique of hypnotic suggestion. And finally he developed that technique which became the basic rule of psychoanalysis the technique of “Free Association”.

Major theoretical constructs

Within the analytic framework, a person is regarded as the recipient of turbulent intrapsychic impulses struggling to be set free. They are inner unknown desires and urges, largely libidinal and aggressive to which the person is inherently (biologically) subject but that he or she continually defend against, creating a reservoir of infantile feelings and wishes that are inaccessible to the conscious self.

Five integral psychoanalytic conception of mind:

1) DYNAMIC CONCEPT Under this concept mental phenomena are a result of continual interaction of forces that opposes one another. There is a conflict between instinctual drives and forces that restrain them. It implies that human behaviour and motivations are active, energy laden and changing at all times. This have a passive connection for a person’s capacity to overcome pathology, to resolve, to adapt, and to mature as the balance of mental forces keeps shifting.

2) TOPOGRAPHICAL CONCEPT Here it refers that mental phenomena reveals themselves at different levels of manifestations, from the deepest recesses of mind (unconscious), to the border of awareness (preconscious), and finally to the surface (conscious). This model laid the groundwork for the aetiological phenomena of “repression”, a process by which forbidden ideas or impulses (mostly sexual) are denied access to the conscious and whose reversal removes the original source of illness.

3) STRUCTURAL CONCEPT The model gave the idea that the mental apparatus is made up of functional unit of ‘tripartite’ nature: the id, ego, and superego. The mental apparatus works around these harsh masters and ego serves as a moderator between the primitive instinctual drives and his/her internalised parental and social inhibitions. Freud, after he elaborated this model in 1926, believed in the notion that “where id was, there shall ego be” and the overall goal of  psychoanalysis was to replace ‘id’ with ‘ego’ in the process of maturation , development , and achievement of health.

4) ECONOMIC CONCEPT Economic perspective relates to how the psychic energy is distributed, discharged, or transformed and how a person fends off psychic threats through variety of defense mechanisms e.g. sublimation, reaction formation, displacement etc. It implicates how ideas and affects are expressed (verbally or symbolically).

5) GENETIC CONCEPT It is unfortunate choice of the name ‘genetic’ as it has nothing to do with genetics as it is commonly known today. It relates to the analytic believe that the intrinsic core of illness resides in a particular period of infantile development (fixation) and regression to the infantile mode is both a manifestation of illness and the development of a technical process within analysis, a transference neurosis, of which the resolution is the essence of classical analytic cure.

Psychoanalytic setting and process

In early approach to therapy Freud felt that recognition by the physician of the patient’s unconscious motivation, the communication of this knowledge to the patient and its comprehension by the patient would of themselves affect a cure. This was the basic doctrine of therapeutic “insight”. Later Freud realised that success of treatment depends on patient’s ability to understand the emotional significance of an experience on an emotional level and on his capacity to retain and use that insight if experiences recur in future. Analytic process refers to the regressive emergence, working through, interpretation, and resolution of transference neurosis whereas analytic situation on the other hand refers to the setting in which analytic process takes place, specifically the positive real relationship between analyst and patient based on therapeutic alliance.

Main approach

Frequency: Regular four to five times/week; 50 minutes.

Duration: long term; usually three to five + years.

Setting: Patient primarily on couch with analyst out of view.

Fundamental rule: Free association.

Analyst role: Principal of evenly suspended attention. Analyst as “mirror”. Rule of abstinence.

Analytic process

A) Phases of analytic process

First phase: Initiation and consolidation of analytic setting relates to patient’s capacity to enter into, establish and sustain a therapeutic alliance. This alliance is a one to one relationship between analyst and patient. The achievement of a special object relation determines the nature and quality of the therapeutic alliance. The establishing of therapeutic alliance requires certain basic capacities in the patient like must have the capacity to maintain basic trust in the absence of gratification, able to maintain self-object differentiation, must have the capacity to accept limitation of reality, to tolerate frustration and acknowledge own limitations. Both the analyst and patient are actively involved in this relationship and it constitutes the essence of the analytic situation.

Second phase: Emergence and analysis of transference neurosis relates to the patient’s capacity to develop genuine transference neurosis and to regress sufficiently to allow transference neurosis to emerge, to be analyzed, and to work through its respective elements. Transference involves reopening and reworking of “oedipal conflicts” and resolution involves development of a capacity to initiate and sustain intrapsychic defenses against instinctual wishes, integration of both autonomous ego and ego ideals in a capacity for positive and constructive identification with parent of same sex, renunciation of sexualised goals in regard to the parent of opposite sex in favour of integration of a positive object relationship with that parent, involves neutralisation or sublimation of aggressive energies mobilised in rivalry with parent of same sex. Working through of the transference aims at resolution of these basic conflicts in order to gain the capacity for meaningful growth that is inherent in the resolution of these oedipal issues.

Third phase: Successful termination and separation from analytic process. The terminal phase of successful analysis concerns itself directly with the issue of autonomy and independence. In the initial phase the analyst was comparable to a parent who responds to the regressive, passive, and dependent aspect of infantile neurosis and in the terminal phase he becomes like the parent of a late adolescent who foster and support the maturation and autonomy of the child. The patient works toward more matured acceptance of realistic limits and mobilises his resources to establish a more secure sense of autonomy and independence. To accomplish the work of terminal phase, patient must have sufficient ego resource to tolerate the pain of loss and to undertake the work of mastery that is necessary for developmental gains. Even after successful termination the analyst remains as an available object much as a good parent who remains an available and supportive object for the child.

B) Treatment techniques

1) Free association: The cornerstone of the psychoanalysis technique is free association. Free association besides providing content for analysis also helps in inducing regression and passive dependence that is connected with establishing the working through the transference neurosis.

2) Resistance: Development of resistance in analysis is quite automatic and independent of patients will as is development of transference itself. The source of resistance is just as unconscious as the source of transference.

One important work in the second phase is working through the resistance in order to facilitate regression to transference neurosis. The resistance offered during analysis enables the analyst to evaluate and become familiar with the defensive organisation of the patients ego and its functions. In this way the resistance not only offer valuable information to the analyst but also offers a channel by which he can approach the patient therapeutically.

3) Interpretation: It is the chief tool available to the analyst in his effort to reduce unconscious resistance. Early in the therapeutic techniques the sole purpose of interpretation was to inform the patient of his unconscious wishes but later it designed to help the patient understand his resistance to spontaneous and helpful self awareness.

It is not so much the analyst insight into the patients psychodynamics that produces progress in analysis , rather it is the ability to help the patient gain this insight for himself by reducing unconscious resistance through appropriate , careful and timed interpretation. 

C) Dynamics of therapeutic process

In the course of analysis the patient undergoes two processes: remembering and reliving which constitutes the dynamics of the treatment process.

Remembering refers to the gradual extension of consciousness back to early childhood at which the core of neurosis was formed.

Reliving refers to actual re-experiencing of those events in the context of the patient’s relationship with the analyst.

1. Transference: Through free association hidden patterns of the patients’ mental organisation fixed at an immature level are brought to life. These are events or fantasies that are part of patients’ private experience.

In the analytic setting the analyst is gradually invested with some of the emotions that accompany them. Patient displaces the feeling he originally directed towards the earlier object onto the analyst who then become alternately a friend or enemy.

This special type of object displacement that is an inevitable concomitant of psychoanalytic treatment is referred to as “transference”

2. Transferance neurosis: Usually develops in the second phase of analysis. The patient who at first was eager for improved mental health, no longer consistently display such motivation during treatment hours rather engage in a continuous battle with the analyst and the only compelling reason for continuing analysis is his desire to attain some kind of emotional satisfaction  from the analyst.

Transference neurosis is governed by three instinctual life characteristics – pleasure principle, ambivalence, repetition compulsion.

One situation after another in the life of the patient is analysed until original conflicts is fully revealed and only then transference neurosis begins to subside and termination of analysis begins from that point.

3. Countertransferance: When the analyst engages in the interaction with his or her own burden of elements coming from his or her own developmental past or that may activate in the course of interaction with the patient, the process is called “countertransference”.

Initially it was thought to be the analyst unconscious response but recent views see it as encompassing the total affective response of the analyst to the patient, whether conscious or unconscious.

Earlier views of countertransference saw it as interfering in the work of analyst, but recent revision has emphasised the possible positive contributions to more effective analytic work from utilisation of countertransference.

The view of countertransference as inspired by Kleinian orientation focuses the understanding of analytic process more or less completely and exhaustively on transference in the patient and countertransference in the analyst and the interactions between them. Thus all responses and reactions of the analyst to the patient are included under the rubric of countertransference.

4. Therapeutic alliance: The therapeutic alliance is based on the one to one collaborative relationship that the patient establishes in interaction with the analyst. This interaction deals with those aspects of therapeutic relation that enable patient and analyst to engage meaningfully and productively in the analytic process with the objective of attaining therapeutic benefit for the patient.

The alliance on these terms would include at least the following elements: empathy, trust, autonomy, responsibility, authority, freedom, honesty, and neutrality.
The therapeutic alliance allows a split of the patient’s ego and the observing part of the patient’s ego allow him/her to allay with the analyst in working relationship and modifying the pathological defenses put by the defensive ego against internal dangerous situations. 

Maintenance of therapeutic alliance require the patient to maintain a self-object differentiation, tolerance and mastery over ambivalence and capacity to distinguish between fantasy and reality in the relationship.

Patient’s requisites

1. High motivation: The desire for health and self-understanding must surpass the neurotic need for unhappiness. The patient must be willing to face issues of time, money, and to endure the pain and frustration associated with sacrificing rapid relief in favour of future cure.

2. Ability to form relationship: The capacity to form, maintain, as well as detach from a trusting object relationship is essential.

3. Psychological mindedness and capacity for insight.

4. Ego strength.

Indications and contraindications

Merton Gill described the indications for psychoanalysis as “the ego is sufficiently damaged that extensive repair is necessary, but sufficiently strong to withstand pressure”. Some indications are:

1. Chronic cases of psychoneurosis including all forms of symptomatic anxiety, obsessional and hysterical neurotic manifestations.

2. Neurotic depression.

3. Some character disorders like narcissistic personality disorder (PD), borderline PD.   

4. Sexual disorders.

In the last two cases results are favourable if neurotic traits (i.e. areas of conflicts) are evident with the symptoms.

Some contraindications:

1. Persons with paranoid/schizoid PD.

2. Substance abuse disorders (narcotic and alcoholic).

3. Antisocial PD.

4. Poor impulse control.

5. Inability to tolerate frustration.

6. Impaired social judgement.

7. Patients with psychosis.

Limitations

The predominant treatment constraints are often economic, relating to the high cost in time and money, both for patient and in training of future practitioners. In addition, because clinical requirements emphasise such requisites as psychological mindedness, verbal and cognitive ability and stable life situation, psychoanalysis may be unduly restricted to a diagnostically, socioeconomically or intellectually advantaged patient population.

Other intrinsic issues pertain to the use and misuse of its stringent rules, whereby overemphasis on technique may interfere with an authentic human encounter between analyst and patient and to a long term risk of interminability by which protracted treatment may become a substitute for life.

References

1. Kaplan and Sadock’s Comprehensive Text Book of Psychiatry; 3rd Edition, Vol 1.

2. Kaplan and Sadock’s Comprehensive Text Book of Psychiatry; 9th Edition, Vol 1 & 2.

3. Vyas and Ahuja, Textbook of Postgraduate Psychiatry.

 

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