The basic method of psychoanalysis is interpretation of the patient’s unconscious conflicts that are interfering with current-day functioning – conflicts that are causing painful symptoms such as phobias, anxiety, depression, and compulsions. Strachey (1936) stressed that figuring out ways the patient distorted perceptions about the analyst led to understanding what may have been forgotten (also see Freud’s paper “Repeating, Remembering, and Working Through”). In particular, unconscious hostile feelings toward the analyst could be found in symbolic, negative reactions to what Robert Langs later called the “frame” of the therapy – the setup that included times of the sessions, payment of fees, and necessity of talking. In patients who made mistakes, forgot, or showed other peculiarities regarding time, fees, and talking, the analyst can usually find various unconscious “resistances” to the flow of thoughts (sometimes called free association).
When the patient reclines on a couch with the analyst out of view, the patient tends to remember more, experience more resistance and transference, and be able to reorganize thoughts after the development of insight – through the interpretive work of the analyst. Although fantasy life can be understood through the examination of dreams, masturbation fantasies (cf. Marcus, I. and Francis, J. (1975), Masturbation from Infancy to Senescence) are also important. The analyst is interested in how the patient reacts to and avoids such fantasies (cf. Paul Gray (1994), The Ego and the Analysis of Defense). Various memories of early life are generally distorted – Freud called them “screen memories” – and in any case, very early experiences (before age two) – can not be remembered (See the child studies of Eleanor Galenson on “evocative memory”).
Variations in Technique
There is what is known among psychoanalysts as “classical technique,” although Freud throughout his writings deviated from this considerably, depending on the problems of any given patient. Classical technique was summarized by Allan Compton, MD, as comprising instructions (telling the patient to try to say what’s on their mind, including interferences); exploration (asking questions); and clarification (rephrasing and summarizing what the patient has been describing). As well, the analyst can also use confrontation to bringing an aspect of functioning, usually a defense, to the patient’s attention. The analyst then uses a variety of interpretation methods, such as dynamic interpretation (explaining how being too nice guards against guilt, e.g. – defense vs. affect); genetic interpretation (explaining how a past event is influencing the present); resistance interpretation (showing the patient how they are avoiding their problems); transference interpretation (showing the patient ways old conflicts arise in current relationships, including that with the analyst); or dream interpretation (obtaining the patient’s thoughts about their dreams and connecting this with their current problems). Analysts can also use reconstruction to estimate what may have happened in the past that created some current issue.
These techniques are primarily based on conflict theory (see above). As object relations theory evolved, supplemented by the work of Bowlby, Ainsworth, and Beebe, techniques with patients who had more severe problems with basic trust (Erikson, 1950) and a history of maternal deprivation (see the works of Augusta Alpert) led to new techniques with adults. These have sometimes been called interpersonal, intersubjective (cf. Stolorow), relational, or corrective object relations techniques. These techniques include expressing an empathic attunement to the patient or warmth; exposing a bit of the analyst’s personal life or attitudes to the patient; allowing the patient autonomy in the form of disagreement with the analyst (cf. I.H. Paul, Letters to Simon.); and explaining the motivations of others which the patient misperceives. Ego psychological concepts of deficit in functioning led to refinements in supportive therapy. These techniques are particularly applicable to psychotic and near-psychotic (cf., Eric Marcus, “Psychosis and Near-psychosis”) patients. These supportive therapy techniques include discussions of reality; encouragement to stay alive (including hospitalization); psychotropic medicines to relieve overwhelming depressive affect or overwhelming fantasies (hallucinations and delusions); and advice about the meanings of things (to counter abstraction failures).
The notion of the “silent analyst” has been criticized. Actually, the analyst listens using Arlow’s approach as set out in “The Genesis of Interpretation”), using active intervention to interpret resistances, defenses creating pathology, and fantasies. Silence is not a technique of psychoanalysis (also see the studies and opinion papers of Owen Renik, MD). “Analytic Neutrality” is a concept that does not mean the analyst is silent. It refers to the analyst’s position of not taking sides in the internal struggles of the patient. For example, if a patient feels guilty, the analyst might explore what the patient has been doing or thinking that causes the guilt, but not reassure the patient not to feel guilty. The analyst might also explore the identifications with parents and others that led to the guilt.
Interpersonal-Relational psychoanalysts emphasize the notion that it is impossible to be neutral. Sullivan introduced the term “participant-observer” to indicate the analyst inevitably interacts with the analysand, and suggested the detailed inquiry as an alternative to interpretation. The detailed inquiry involves noting where the analysand is leaving out important elements of an account and noting when the story is obfuscated, and asking careful questions to open up the dialogue.
Group Therapy and Play Therapy
Although single-client sessions remain the norm, psychoanalytic theory has been used to develop other types of psychological treatment. Psychoanalytic group therapy was pioneered by Trigant Burrow, Joseph Pratt, Paul F. Schilder, Samuel R. Slavson, Harry Stack Sullivan, and Wolfe. Child-centered counseling for parents was instituted early in analytic history by Freud, and was later further developed by Irwin Marcus, Edith Schulhofer, and Gilbert Kliman. Psychoanalytically based couples therapy has been promulgated and explicated by Fred Sander, MD. Techniques and tools developed in the 2000s have made psychoanalysis available to patients who were not treatable by earlier techniques. This meant that the analytic situation was modified so that it would be more suitable and more likely to be helpful for these patients. M.N. Eagle (2007) believes that psychoanalysis cannot be a self-contained discipline but instead must be open to influence from and integration with findings and theory from other disciplines.
Psychoanalytic constructs have been adapted for use with children with treatments such as play therapy, art therapy, and storytelling. Throughout her career, from the 1920s through the 1970s, Anna Freud adapted psychoanalysis for children through play. This is still used today for children, especially those who are preadolescent (see Leon Hoffman, New York Psychoanalytic Institute Center for Children). Using toys and games, children are able to demonstrate, symbolically, their fears, fantasies, and defenses; although not identical, this technique, in children, is analogous to the aim of free association in adults. Psychoanalytic play therapy allows the child and analyst to understand children’s conflicts, particularly defenses such as disobedience and withdrawal, that have been guarding against various unpleasant feelings and hostile wishes. In art therapy, the counselor may have a child draw a portrait and then tell a story about the portrait. The counselor watches for recurring themes—regardless of whether it is with art or toys.
Cultural Variations
Psychoanalysis can be adapted to different cultures, as long as the therapist or counseling understands the client’s culture. For example, Tori and Blimes found that defense mechanisms were valid in a normative sample of 2,624 Thais. The use of certain defense mechanisms was related to cultural values. For example Thais value calmness and collectiveness (because of Buddhist beliefs), so they were low on regressive emotionality. Psychoanalysis also applies because Freud used techniques that allowed him to get the subjective perceptions of his patients. He takes an objective approach by not facing his clients during his talk therapy sessions. He met with his patients wherever they were, such as when he used free association — where clients would say whatever came to mind without self-censorship. His treatments had little to no structure for most cultures, especially Asian cultures. Therefore, it is more likely that Freudian constructs will be used in structured therapy (Thompson, et al., 2004). In addition, Corey postulates that it will be necessary for a therapist to help clients develop a cultural identity as well as an ego identity.