The Applied Science of Psychoanalytic Therapy

In my previous post, I discussed essential concepts of Sigmund Freud’s theory of psychoanalysis, that is, his basic science. This month I want to present the practice or applied science of psychoanalytic therapy.
 
Engineers presuppose fundamental concepts of physics and chemistry, along with additional concepts unique to their specialty. Subsequently they apply all of this knowledge to specific cases to build particular, concrete machines and particular, distinct bridges to enhance human life. History, the concretes of a specific case, as well as theory, the universals of the science, are both involved in the practical application of concepts to achieve a specific goal.
 
Similarly, psychoanalytic therapists take Freud’s basic concepts of psychoanalysis, along with specific knowledge of each patient’s personality, character, and history, and apply these notions to help the individual patient become more independent and happy.
 
The essence of psychoanalytic therapy, according to Freud, is the process of talk therapy with the goal of making the unconscious conscious. It means unearthing or digging deep—he often uses archeology as a metaphor for psychotherapy—in the unconscious to find repressed ideas associated with disturbing events and to encourage the patient to re-experience the original emotions. This “abreaction,” which I suggested in my October post was an early form of derepression, became less important (33-34, 219) in Freud’s later years when he began to put more emphasis on the patient’s effort of overcoming resistance to recall and talk about what was painful and repressed.
 
The treatment method of talk therapy, as I mentioned last month, was learned from Josef Breuer (30) who encouraged his patient Anna O. to reminisce about early disturbing experiences that might have led to her conversion hysteria (paralyzed arm among other psychosomatic ailments). In the process of this therapy she said jokingly that she was chimney sweeping, but more seriously described the method as the talking cure. In the early years, Breuer and Freud called this the cathartic method, a cleansing or purifying of the soul. For some years, Freud used hypnosis to overcome resistance, gradually abandoning it in favor of the talk method of finding connections to early and forgotten events, thoughts, and emotions.
 
In the last two sentences of Lecture 31 in Freud’s 1933 New Introductory Lectures on Psycho-Analysis, he writes, “Where it was, there should become I. [Therapeutic effort] is a cultural achievement somewhat like the draining of the Zuyder Zee” (translation Bruno Bettelheim, 61, 62, my italics). That is, just as the Dutch reclaimed land from the sea, so also therapists help patients reclaim their conscious souls (the I) from the unconscious it.*
 
An important concept of therapy that Freud discovered by chance was transference, the idea that patients, as they improve, begin to associate the therapist with an important person from childhood, usually a parent, thus transferring their feelings about this person, both good and bad, to the therapist (An Outline of Psychoanalysis, 29-32). Often the patients feel an unconditional love (which Carl Rogers, 61-62, in later years called an “unconditional positive regard”) from the therapist that they likely did not experience from their parents. Sometimes, though, anger and hostility may be felt, depending on the type of childhood the patient experienced. And on occasion a patient of the opposite sex may fall in love with the therapist—one young female patient flung her arms around Freud’s neck, convinced that they were in love with each other, and Breuer’s patient, Anna O, at the end of her treatment persuaded herself that she was carrying his baby!
 
Once Freud identified these transference reactions, he identified their value in therapy. Once the patient realizes these feelings toward the therapist are displacements, the patient becomes more motivated to overcome resistance to probe more deeply into the unconscious to identify forgotten, repressed thoughts and feelings.**
 
The applied science of psychotherapy as developed and practiced by Freud does not differ much from what nearly all psychologists and psychiatrists do today. Freud’s so-called free association is more of a probing of the patient’s subconscious in an uncritical, unjudgmental manner to encourage thoughts and emotions to rise to consciousness. Freud’s technique, as becomes clear in his many discussions of therapy, is not the caricature we sometimes see today with the therapist saying repeatedly, “uh-huh, uh-huh,” and not much else. In fact, Freud often explores a patient’s line of thought and offers hypotheses about earlier unconscious ideation. His goal, after all, is to help patients gain or regain their independence—Freud’s word (Outline, 26).
 
The Freudian couch? Initially a gift from a patient in 1890; the carpet covering added by Freud “gave his patients a non-medical bed to lie on” and “the sense of being sheltered from one’s daily cares.” In addition, many patients were female and in his day understandably uncomfortable talking about sex while looking at a man. Freud also did not want his patients attempting to read his facial expressions, nor did her take notes, which he believed to be distracting.
 
Free association? Einfall, according to Bettelheim (94-96), a word that  means sudden or chance idea or thought, would lead Freud to ask, “What comes to mind?” or “What is connected with that?” Freie assoziation were words used by Freud only after the technique had become established and then Einfall was described and translated into English as such. The modifier “free” or  freie, Bettelheim writes, puts too much emphasis on the need for conscious effort, rather than emotional spontaneity coming from the unconscious.
 
The fundamental rule of psychoanalytic therapy, as Freud refers to it, is that nothing is off the table for discussion (Outline, 28-29). Whatever connections come to mind, including especially painful, nonsensical, or allegedly unimportant, thoughts must be expressed while on the couch. This includes the content and memory of dreams.
 
 
Assessment of Freud. Contributions to psychology? Nearly everything—from the nature of the conscious and subconscious mind to the cause of neurosis and its treatment in therapy. Talk therapy today is the dominant technique of psychotherapists (unless, unfortunately, they are the psychiatrists who prescribe psychotropic drugs to allegedly treat and cure psychological problems). What else would therapists do but talk to their patients? What nearly all today do not do is mention the words introspection, free will, or the sub- or unconscious, the former two because they are afraid of being accused of being “unscientific” or even religious, the latter, unless they are psychoanalysts, of being accused of Freudianism.
 
Over the years, ideation has become more explicit as thinking errors in cognitive psychology and in the work of Yochelson and Samenow on the criminal personality. It has become more precise as core evaluations in the psychology of Edith Packer (chap. 1).
 
As for Freud’s alleged weak ego—the I—let me quote him in Inhibition, Symptom, and Fear (162).*** In this work, Freud points out the “numerous voices” (other psychoanalysts) who seem to want to make the so-called weakness of the I one of the “central pillars” of psychoanalysis. Freud responds: “Shouldn’t their sheer awareness of how repression actually works deter psychoanalysts in particular from so enthusiastically embracing such an extreme and partisan position?” The whole point of therapy being to reclaim and support the I.
 
What does impinge on and reduce the power of the conscious mind to control our lives is Freud’s determinism. His search for non-volitional causes of behavior is what I believe led him to focus heavily on the drives, rather than ideation, and specifically on the alleged death or destructiveness drive to explain the harmful and detrimental behavior of his patients. Though the notion of a strong unconscious has a long history, going back to Plato, free will is what enables us to learn how to introspect to explain and change our feelings deriving from an un- (or sub-) conscious “chaos” or “cauldron full of seething excitations,” as Freud describes it (New Introductory Lectures, 91). The chaos is something we have put there, and this means we can, through introspection, clean up the mess.
 
With good parenting and teaching, one would hope, psychology of the future will help prevent the mess from occurring in the first place.
 
 
* The standard translation (100) of the first sentence is “Where id was, there ego shall be.” Or, as I rephrased it in an updated form in Independent Judgment and Introspection (176), using the psychology of Edith Packer, “Where subconscious, mistaken conclusions were, there confident and independent self-assertion shall guide.” See Bettelheim’s discussion (61-64) of Goethe’s Faust, which Freud knew well, and Faust’s struggles to reclaim his soul from the devil—an apt analogy to describe what many of Freud’s patient’s felt, and most likely, what many patients today feel.
 
** Edith Packer minimized the value of transference, but did describe herself as a “friend for hire,” which I would say was a strong motivating force for patients who likely, at the time, did not have many good, that is, understanding and helpful, friends.
 
*** This 2003 translation uses the word “fear” instead of the customary “anxiety” because, the translator notes, it is the typical German meaning of Angst. When Freud means anxiety, he uses the word Ängstlichkeit or Angstneurose for anxiety neurosis (note 3, 264-65).
 
 
Postscript to Students of Ayn Rand. I regret having to make the following comment about Ayn Rand and Leonard Peikoff. I see no evidence that either one read much or any of Sigmund Freud. Rand wrote that Freud was one of Europe’s “hand-me-downs” and Peikoff caricatured Freud’s view of man as an “ordure [excrement]-strewn pervert.” I believe that this post and my previous six about Freud speak for themselves. Ayn Rand said to both Nathaniel Branden and Edith Packer that she did not know anything about psychology. Having known Dr. Peikoff for many years, I do not believe he knows much about it either. A strong infusion of psychology into Ayn Rand’s philosophy is desperately needed today.

The Basic Science of Psychoanalysis

“Basic sciences,” as I wrote in last month’s post, “are fundamental sciences, such as physics, biology, and psychology, on which applied sciences rest, such as, respectively, engineering, medicine, and psychotherapy.”
 
Let me now summarize in brief the basic science of psychoanalysis. Freud says that human beings possess needs that give rise to drives, or urges to act, to satisfy those needs. The process requires mental activity to identify what will satisfy the need and action to attain it. The causal impetus from these mostly unconscious biological drives is what Freud calls the “pleasure principle,” though a better translation of lust, according to H. F. Brull, would be joy or desire.
 
For example, when dying of thirst on a hot summer morning, I often feel a strong desire for a glass of water and experience joy in its consumption. The “reality principle” of our reasoning mind, however, can interfere with, detour, or adapt my unconscious drive because of what is required for daily life in the world.
 
The I may remind us, in other words, as it often does me, soon after drinking the cold glass of water that perhaps it was not a good idea and that sips of water with food would have produced a better outcome. The upper I, our memories of parental influence (plus other influences), may also have something to say about this reminding us not to drink too much water on an empty stomach in the morning, unaccompanied by food.
 
This in a highly simplified nutshell is the essence of Freud’s theory of normal psychology. Deficiencies in meeting our innate (psychological) needs lead to neurosis.
 
Hunger and thirst, of course, are not the drives that Freud focuses on, though he does use them as analogies.* His main drive is the libido, a Latin word adopted by him that means wish, desire, or love. In his younger years it meant the sex urge, but he broadened it later to mean emotional energy that originates in our sexuality, expressing our sense of self. When connected to the I-drive, it emphasizes and expresses self-assertion (Brull’s preferred translation for Selbstbehauptung, as opposed to the standard translation of “self-preservation”). Libido is the life force or love drive that motivates us.
 
Sense of self can be interpreted as self-esteem, which Freud was not unaware of as a psychological need, and he did observe its deficiency in many of his patients. Freud, however, did not emphasize self-esteem as a need or drive, though in several places he quotes patients expressing precisely what Edith Packer calls core evaluations. “I always had a low opinion of myself,” says one patient (Studies on Hysteria, 278). And “I can’t accomplish anything. I can’t succeed in anything,” says another (Beyond the Pleasure Principle, 59). Loss of love in childhood, says Freud, can lead to “a legacy of diminished self-feeling amounting to a narcissistic scar” (58), the German word for self-feeling being Selbstgefühls, which also can be translated as self-esteem, though the former is probably more correct.
 
Self-feeling, rather than self-esteem, is more in line with Freud’s concept of narcissism, a self-absorption of children, and adults who are physically or mentally ill. That is, narcissists lack maturity (in the case of children) or health (in adults) to allow themselves to focus on and love—that is, to invest one’s libido in—other people or even material goods to enhance their lives. Being in love, says Freud, increases our self-feeling by reducing narcissism. Suffering neurosis, however, reduces self-feeling, which leads to various symptoms, including the sense of inferiority that most neurotics experience.
 
Narcissism for Freud is inherent in all of us from birth as part of the libido drive that most of us do not and probably cannot overcome. Sublimation, or rising above the lower biological drives, means, for example, pursuing de-sexualized artistic or intellectual careers. Such paths, however, he says, are not open to everyone.
 
In my words, I would say that the libido drive is the pursuit of values, including romantic values, in oneself and in the pleasure of the company of others. The pursuit of mistaken or unhealthy values then is what leads to neurosis.
 
In childhood, this pursuit of values includes the exploration of our sexuality.
 
According to Freud, sexuality develops in childhood in three stages of sensuousness: the oral, sucking of the breast and thumbs; the sadistic-anal, of learning to control defecation (and maybe even playing with the feces) coinciding with teething and therefore “sadistic” biting (though I would put “terrible twos” here, the beginning of self-assertion, but Freud does not mention it); and the genital, with all the questions about where babies come from and the differences between the sexes that follow, and of course, the pleasure of touching the genitals.
 
This was radical for Freud to assert in his time, that sexuality begins before puberty. Sexuality, as he points out, is a broader term than the sex or sexual relations of adults. His Three Essays on the Theory of Sexuality is a daring and non-judgmental (that is, de-moralized) masterpiece for his time, covering all forms of sexuality, which include all the known deviations from penile-vaginal intercourse. A fixation on the foot or a piece of clothing—fetishes, in other words—or inversions (for example, voyeurism at the same or opposite sex), Freud points out, develop early and cause neurotic problems in adulthood.
 
Freud focused so much on sex because his Victorian culture produced in his patients problems that derived from their early childhood experiences, and especially from the often negative reactions of their parents. Women, for example, may not have been taught or known anything about sex and young men, in addition to suffering threats of having their penises cut off, were considerably bothered by coitus interruptus, the withdrawal method of birth control, and impotence.**
 
When the libido, also called the Eros drive, misfires, the death or destructiveness drive leads us to a “flight into illness” and “withdrawal from reality” (Five Lectures on Psycho-Analysis, 54). The misfiring produces “excitation” (one of Freud’s neurophysiological terms) experienced during disturbing or frightening events, often in childhood, that were not dealt with appropriately at the time. Thus, the emotions of multiple events are condensed and displaced into a symptom, while the ideation of the events is repressed.
 
In my summary of the “Little Hans” case (October post) I pointed out how anxiety, the fear with no apparent object, is experienced in response to the “excitations” of disturbing events, which can also be described as a misfiring or blocking of the libido, and how the ideas associated with the events are subsequently repressed or pushed out of conscious awareness, not recurring sometimes until adulthood and then only as neurotic symptoms. Repression is the fundamental defense that the I uses to protect itself, but there are other defenses, such as reaction formation, projection, and regression, as well as displacement and sublimation.
 
Most of these concepts of defense—reaction formation the exception—predate Freud, but he gave them new and more developed meanings, especially as they apply to psychology. The Oedipal Complex is original to Freud and is his metaphor for childhood injury that results from parental reactions to the overemphasis of libido on one parent, usually the mother, and underemphasis on the other, the father.
 
The above, I hope, presents a sense of Freud’s large and complex system, or at least some of his key concepts. Next month, Freud’s applied science of psychotherapy.
 
 
* See especially Freud’s (90-92) discussion of the evolution of psychoanalytic theory that began with what he called the “popular” distinction between the drives of hunger and love.
 
** Josef Breuer (21), from whom Freud learned the method of talk therapy, in 1880-82 treated a twenty-one year old woman whose “sexuality,” he described, “was astonishingly undeveloped.” The woman was Bertha Pappenheim but in print was referred as Anna O.