Psychoanalysis: Freud’s Psychoanalytic Approach to Therapy

The primary assumption of psychoanalysis is the belief that all people possess unconscious thoughts, feelings, desires, and memories.

According to Freud, neurotic problems in later life are a product of the conflicts that arise during the Oedipal phase of development. These conflicts may be repressed because the immature ego is unable to deal with them at the time.

Basic Assumptions

• Psychoanalytic psychologists see psychological problems as rooted in the unconscious mind.
• Manifest symptoms are caused by latent (hidden) disturbances.
• Typical causes include unresolved issues during development or repressed trauma.
• Freud believed that people could be cured by making conscious their unconscious thoughts and motivations, thus gaining insight.
• Treatment focuses on bringing the repressed conflict to consciousness, where the client can deal with it.

Psychoanalytic therapy aims to create the right sort of conditions so that the patient can bring these conflicts into the conscious mind, where they can be addressed and dealt with.  Only by having a cathartic (i.e., healing) experience is the person helped and “cured.”

How Can We Understand The Unconscious Mind?

Remember, psychoanalysis is a therapy as well as a theory. Psychoanalysis is commonly used to treat depression and anxiety disorders.

In psychoanalysis (therapy), Freud would have a patient lie on a couch to relax, and he would sit behind them taking notes while they told him about their dreams and childhood memories.  Psychoanalysis would be a lengthy process, involving many sessions with the psychoanalyst.

During analysis, the analyst interprets the patient’s thoughts, actions and dreams, and points out their defenses. By carefully waiting until the patient himself is about to gain the same insight the analyst can maximize the impact of the interpretation.

Related to these interpretations is the problem of the patient’s denial. The analyst may well have reason to believe that a patient’s denial of an interpretation offered by the analyst is another example of the defensive process.

Analysis of defenses is emphasized by contemporary psychoanalysts (known as ego analysts) who dispute the relatively weak role that Freud assigned the ego (Davison & Neale, 1994). They argue that defence mechanisms are the ego’s unconscious tools for warding off a confrontation with anxiety.

Due to the nature of defense mechanisms and the inaccessibility of the deterministic forces operating in the unconscious, psychoanalysis in its classic form is a lengthy process, often involving 2 to 5 sessions per week for several years.

Of particular significance during psychoanalysis are the patient’s attempts at resistance. They may attempt to block discussion by changing the subject quickly, for example, or even neglecting to turn up for therapy. Freud considered these resistances a valuable insight into uncovering sensitive areas in the patient’s unconscious mind.

This approach assumes that the reduction of symptoms alone is relatively inconsequential, as if the underlying conflict is not resolved, more neurotic symptoms will be substituted.

The analyst typically is a “blank screen,” disclosing very little about themselves in order that the client can use the space in the relationship to work on their unconscious without interference from outside.

The psychoanalyst uses various techniques as encouragement for the client to develop insights into their behavior and the meanings of symptoms, including inkblots, parapraxes, free association, interpretation (including dream analysis), resistance analysis and transference analysis.

1) Rorschach inkblots

Due to the nature of defense mechanisms and the inaccessibility of the deterministic forces operating in the unconscious,

The Rorschach inkblot itself doesn”t mean anything, it’s ambiguous (i.e., unclear). It is what you read into it that is important. Different people will see different things depending on what unconscious connections they make.

The inkblot is known as a projective test as the patient “projects” information from their unconscious mind to interpret the inkblot.

However, behavioral psychologists such as B.F. Skinner have criticized this method as being subjective and unscientific.

2) Freudian Slip

Unconscious thoughts and feelings can transfer to the conscious mind in the form of parapraxes, popularly known as Freudian slips or slips of the tongue. We reveal what is really on our mind by saying something we didn’t mean to.

Freud believed that these were no accidents but were due entirely to the workings of the unconscious. As such, they were a valuable source of insight into this part of the human mind. These are more technically known as parapraxes.

For example, a nutritionist giving a lecture intended to say we should always demand the best in bread, but instead said bed. Another example is where a person may call a friend’s new partner by the name of a previous one, whom we liked better.

Freud believed that slips of the tongue provided an insight into the unconscious mind and that there were no accidents, every behavior (including slips of the tongue) was significant (i.e., all behavior is determined).

3) Free Association

A key part of learning to conduct psychoanalytic psychotherapy involves developing skills and techniques aimed at accessing and understanding unconscious processes.

This includes facilitating the client’s free association, where the client expresses whatever thoughts or feelings come to mind without censorship. As unconscious ideas and emotions emerge, the therapist helps the client explore and make meaning of them.

Free association is a psychoanalytic term used to describe the free association of ideas that can give an insight into the unconscious mind of the patient.

In free association, the patient is encouraged to speak freely and to verbalize anything that comes to mind. In this way the patient may be able to bring content to the surface that has previously been censored by the ego.

This technique involves a therapist giving a word or idea, and the patient immediately responds in an unconstrained way with the first word that comes to mind. The analyst then offers an interpretation of the relationship observed.

It is hoped that fragments of repressed memories will emerge in the course of free association, giving an insight into the unconscious mind.

Free association may not prove useful if the client shows resistance, and is reluctant to say what he or she is thinking.

On the other hand, the presence of resistance (e.g., an excessively long pause) often provides a strong clue that the client is getting close to some important repressed idea in his or her thinking, and that further probing by the therapist is called for.

Freud reported that his free-associating patients occasionally experienced such an emotionally intense and vivid memory that they almost relived the experience.  This is like a “flashback” from a war or a rape experience.

Such a stressful memory, so real it feels like it is happening again, is called an abreaction.  If such a disturbing memory occurred in therapy or with a supportive friend and one felt better–relieved or cleansed–later, it would be called a catharsis.

Frequently, these intensely emotional experiences provided Freud a valuable insight into the patient’s problems.

4) Dream Analysis

According to Freud, the analysis of dreams is “the royal road to the unconscious.” He argued that the conscious mind is like a censor, but it is less vigilant when we are asleep.

In dream analysis, the analyst attempts to unravel and interpret the symbolic nature of the patient’s dreams. The true concerns of the patient are often disguised in their dreams and may be experienced symbolically, i.e. they dream about something that represents their concern, rather than dreaming directly about the concern itself. The true concerns of the patient are often disguised in this symbolic form to protect the conscious mind from developing full awareness of the underlying concern.

As a result, repressed ideas come to the surface – though what we remember may well have been altered during the dream process.

As a result, we need to distinguish between the manifest content and the latent content of a dream. The former is what we actually remember.

The latter is what it really means. Freud believed that very often the real meaning of a dream had a sexual significance and in his theory of sexual symbolism, he speculates on the underlying meaning of common dream themes.

5) Transference Analysis

Another core technique is examining transference, which refers to how the client relates to the therapist in ways that unconsciously reflect early important relationships, and countertransference, the therapist’s own unconscious reactions to the client that can give insight into the therapeutic relationship dynamics.

So, trainees learn to attend carefully to the emotional interchanges within the therapy relationship as a source of insight into both parties’ unconscious relational patterns stemming from their developmental histories.

Of key importance in psychoanalytic therapy is transference. Freud had originally noticed that his patients sometimes felt and acted toward him as if he were an important person from the patient’s past.

Sometimes, these feelings were positive, but sometimes they were negative and hostile. Freud assumed these were relics of attitudes held toward these important persons in the patient’s past.

Freud felt that this transference was an inevitable aspect of psychoanalysis, and used it to explain to patients the childhood origins of many of the concerns and fears.

In psychoanalysis, transference is seen as essential to a complete cure. Analysts use the fact that transference is developing as a sign that an important repressed conflict is nearing the surface.

Countertransference

In psychoanalysis, countertransference refers to the emotional reactions and unconscious biases a therapist might have towards a patient, often influenced by the therapist’s own past experiences or unresolved feelings.

It’s the therapist’s emotional response to the patient’s transference.

Clinical Applications

Psychoanalysis (along with Rogerian humanistic counseling) is an example of a global therapy (Comer, 1995, p. 143) which has the aim of helping clients bring about a major change in their whole perspective on life.

This rests on the assumption that the current maladaptive perspective is tied to deep-seated personality factors. Global therapies stand in contrast to approaches which focus mainly on a reduction of symptoms, such as cognitive and behavioral approaches, so-called problem-based therapies.

Psychoanalytic therapy has been seen as appropriate mainly for the neurotic disorders (e.g. anxiety and eating disorders) rather than for psychotic disorders such as schizophrenia. It is also used for depression although its effectiveness in this area is more questionable because of the apathetic nature of the depressive patients.

A related problem is the greater likelihood of transference in depressive patients undergoing psychoanalysis. They are likely to show extreme dependency upon important people in their life (including their therapist) and more likely to develop transference (Comer, 1995).

Anxiety disorders such as phobias, panic attacks, obsessive-compulsive disorders and post-traumatic stress disorder are obvious areas where psychoanalysis might be assumed to work.

The aim is to assist the client in coming to terms with their own id impulses or to recognize the origin of their current anxiety in childhood relationships that are being relived in adulthood.  Svartberg and Stiles (1991) and Prochaska and DiClemente (1984) point out that the evidence for its effectiveness is equivocal.

Salzman (1980) suggests that psychodynamic therapies generally are of little help to clients with specific anxiety disorders such as phobias or OCDs but may be of more help with general anxiety disorders.

Salzman (1980)  expresses concerns that psychoanalysis may increase the symptoms of OCDs because of the tendency of such clients to be overly concerned with their actions and to ruminate on their plight (Noonan, 1971).

Comer also suggests that psychoanalysis may not be appropriate for patients suffering from obsessive-compulsive disorder in that it may inadvertently increase their tendency to over-interpret events in their life.

Depression may be treated with a psychoanalytic approach to some extent.  Psychoanalysts relate depression back to the loss every child experiences when realizing our separateness from our parents early in childhood.  An inability to come to terms with this may leave the person prone to depression or depressive episodes in later life.

Treatment then involves encouraging the client to recall that early experience and to untangle the fixations that have built up around it.  Particular care is taken with transference when working with depressed clients due to their overwhelming need to be dependent on others.

The aim is for clients to become less dependent and to develop a more functional way of understanding and accepting loss/rejection/change in their lives.

Shapiro and Emde (1991) report that psychodynamic therapies have been successful only occasionally.  One reason might be that depressed people may be too inactive or unmotivated to participate in the session.  In such cases a more directive, challenging approach might be beneficial.

Another reason might be that depressives may expect a quick cure and as psychoanalysis does not offer this, the client may leave or become overly involved in devising strategies to maintain a dependent transference relationship with the analyst.

Critical Evaluation

• Therapy is very time-consuming and is unlikely to provide answers quickly.
• People must be prepared to invest a lot of time and money into the therapy; they must be motivated.
• They might discover some painful and unpleasant memories that had been repressed, which causes them more distress.
• This type of therapy does not work for all people and all types of disorders.
• The nature of Psychoanalysis creates a power imbalance between therapist and client that could raise ethical issues.

There has been criticism in recent years that if psychoanalysis is of benefit to people, it is only of benefit to those who possess certain qualities. The acronym YAVIS has been used to indicate that patients who are young, attractive, verbal, intelligent, and successful would be the ones most likely to benefit from psychoanalysis.

Few studies appear to support the first three of these suggestions, although as well as the latter two suggestions there is evidence that psychoanalysis also works best with those clients who are highly motivated and have a positive attitude towards therapy.

Eysenck (1952) delivered the most damaging indictment of psychoanalysis when he reviewed studies of therapeutic outcomes for neurotic patients. He found that about half recovered within two years. What was so damning for psychoanalysis was that for similar patients who received no treatment at all (waiting list controls), the figure was about two thirds.

Critics of Eysenck’s findings discovered that he had made a number of arbitrary judgements about ‘recoveries’ that were unfavorable to the groups that received psychoanalytic treatments.

Bergin (1971) found that by selecting different outcome criteria, improvement in the psychoanalytically treated group rose to 83% whilst the percentage of control group patients showing significant improvement dropped to 30%.

Fisher and Greenberg (1977), in a review of the literature, conclude that psychoanalytic theory cannot be accepted or rejected as a package, “it is a complete structure consisting of many parts, some of which should be accepted, others rejected and the others at least partially reshaped.”

Eysenck’s claims against the effectiveness of psychoanalysis showed the difficulties of evaluation in this area. Individual differences in patients and therapists, and the relationship between them, might confound attempts to measure the effectiveness of a particular type of treatment. Measuring the outcome of treatment may also present problems in defining what is meant by ‘cure’.

Corsini and Wedding (1995, 2013) claim that, depending on the criteria involved, estimates of ‘cure’ as a result of psychoanalysis range from 30% to 60%.

Although changes in the occurrence of symptoms might be a suitable way of measuring the effectiveness of behaviorist techniques, the effectiveness of psychoanalytic therapy, which typically spans several years, is more subjective, measurable only by the extent to which the clients themselves feel that their condition has improved .

Fonagy (1981) questions whether attempts to validate Freud’s approach through laboratory tests have any validity themselves.

Freud’s theory questions the very basis of a rationalist, scientific approach and could well be seen as a critique of science, rather than science rejecting psychoanalysis because it is not susceptible to refutation.

The case study method is criticized as it is doubtful that generalizations can be valid since the method is open to many kinds of bias (e.g., Little Hans).

However, psychoanalysis is concerned with offering interpretations to the current client, rather than devising abstract dehumanized principles.

Anthony Storr (1987), the well-known psychoanalyst appearing on TV and Radio 4’s “All in the Mind”, holds the view that whilst a great many psychoanalysts have a wealth of “data” at their fingertips from cases, these observations are bound to be contaminated with subjective personal opinion and should not be considered scientific.

Neo Freudians

Subsequent psychoanalytic theorists built upon but also challenged Freud’s drive theory.

Object relations theory shifted focus to relationships and attachment, with key figures like Melanie Klein, Donald Winnicott, and John Bowlby emphasizing how internal working models of self/other based on early caretaker relationships shape personality and relational patterns.

Harry Stack Sullivan and interpersonal psychoanalysis highlighted social and cultural factors influencing mental health. Heinz Kohut’s self-psychology focused on empathy, attunement, and disorders of the self like narcissism.

Intersubjective and relational psychoanalysis theories view the client’s and therapist’s subjectivities as co-created in an intersubjective field, with attention to enactments and dissociated self states, especially for trauma survivors.

Attachment Theory vs Psychoanalysis

Attachment theory, developed by John Bowlby, and psychoanalytic theory, developed by Sigmund Freud, offer complementary perspectives on human development and relationships.

While attachment theory reacted against some psychoanalytic views, like drive theory, the two approaches converge on many topics. Both see early childhood experiences as shaping internal models that influence adult relationships and behavior.

Attachment research provides empirical evidence that unresolved issues from childhood perpetuate across generations, a key psychoanalytic claim. Concepts like internal working models and secure base align with psychoanalytic ideas like transference and the therapeutic relationship fostering insight.

However, attachment theory more strongly emphasizes the impact of actual childhood events, whereas psychoanalysis highlights inner reality and fantasy.

Both offer useful frameworks for understanding how relational patterns persist or change across the lifespan. Their differences can spark productive dialogue on the roles of inner and outer reality in development. 

Training

Psychoanalytic education also involves the trainee undergoing extensive personal therapy, where through experiencing the therapy process directly they gain firsthand insight into their own psychological conflicts, attachment history, unconscious reactions, and clinical blind spots.

This helps develop self-awareness and attunement needed to understand and respond helpfully to clients’ unconscious communications.

Finally, cultural competence requires analysts to engage in ongoing self-examination around differences and power dynamics related to their own and their clients’ sociocultural identities and experiences.

Unconscious assumptions, biases, stereotypes etc. rooted in culture and privilege/oppression influence clinical perceptions and relationships, so their ongoing reflection upon is considered imperative.

The multiple layers of self-exploration around unconscious processes in one’s personal therapy, clinical work, supervision, and sociocultural context form the bedrock of psychoanalytic clinical education and skill development.

Learning Check: You are the Therapist