Psychoanalysis

Part of a series of articles on Psychoanalysis

Constructs Psychosexual development Psychosocial development Conscious %u2022 Preconscious %u2022 Unconscious Id, ego, and super-ego Libido %u2022 Drive Transference %u2022 Sublimation %u2022 Resistance Important Figures Sigmund Freud %u2022 Carl Jung Alfred Adler %u2022 Otto Rank Anna Freud %u2022 Margaret Mahler Karen Horney %u2022 Jacques Lacan Ronald Fairbairn %u2022 Melanie Klein Harry Stack Sullivan Erik Erikson %u2022 Nancy Chodorow Susan Sutherland Isaacs Ernest Jones %u2022 Heinz Kohut John Bowlby Important works The Interpretation of Dreams Four Fundamental Concepts of Psychoanalysis "Beyond the Pleasure Principle" Civilization and Its Discontents Schools of Thought Self psychology %u2022 Lacanian Analytical psychology %u2022 Object relations Interpersonal %u2022 Relational Attachment %u2022 Ego psychology

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Today psychoanalysis comprises several interlocking theories concerning the functioning of the mind. The term also refers to a specific type of treatment in which the "analysand" (analytic patient) verbalizes thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the unconscious conflicts causing the patient's symptoms and character problems; and then explains these formulations ("interprets" them) to the patient to create insight for resolution of the problems. The discipline was founded by Sigmund Freud (1856-1939).

In the past 70 years or so, infant and child research, and new discoveries in adults have led to further modification of theory. The specifics of the analyst's interventions typically include confronting and clarifying the patient's pathological defenses, wishes and guilt. Through the analysis of conflicts, including those contributing to "resistance" (unconscious reluctance to engage in treatment or in free associating), and those involving transference onto the analyst of childish, distorted reactions, psychoanalytic treatment can clarify how patients unconsciously are their own worst enemies: how unconscious, symbolic reactions, that have been stimulated by the current-day experiences, are interfering with the analysand's enjoyment of life and causing symptoms.

A Brief History of the Field

Unconscious functioning was discussed by Plato, and treatments were attempted by Avicenna.^[1] It was described more clearly and more completely by Sigmund Freud, who modified his theories several times over a period of almost 50 years (1889-1939) of attempting to treat patients who suffered with mental problems.

Psychoanalysis was developed in Vienna in the 1890s by Sigmund Freud, a neurologist interested in finding an effective treatment for patients with neurotic or hysterical symptoms. Freud became sensitized to the existence of mental processes that were not conscious as a result of his neurological consulting job at the Kinderkrankenhaus (Children's Hospital), where he noticed that many aphasic children had no organic cause for their symptoms. He wrote a monograph about this (Freud, S (1891). On Aphasia. NY: International Universities Press, 1953. ). He also became aware of the experimental treatment, a combination of hypnotism and "catharsis" done by "abreaction", his older mentor and colleague, Dr. Josef Breuer, was using to treat the now famous patient, Anna O.

In the late 1880s, Freud obtained a grant to study with Jean-Martin Charcot, the famed neurologist and syphilologist, at the Salpêtrière in Paris. Charcot had become interested in patients who had symptoms that mimicked general paresis, the psychotic illness that occurs due to tertiary syphilis. Charcot had found that many patients experienced paralyses, pains, coughs, and a variety of other symptoms with no demonstrable physical etiology (cause). Prior to Charcot's work, women were thought to have a wandering uterus (the name hysteria means this in Greek). But Freud learned that men could have psychosomatic symptoms as well. As a result of talking with patients, Freud learned that the majority complained of sexual problems, especially coitus interruptus as birth control, which surprised him greatly. He first suspected their problems stemmed from cultural restrictions on sexual expression, and devised in 1900 what today is called "topographic theory", in Chapter VII of one of his most famous books, The Interpretation of Dreams. In this theory, which he later more or less discarded in 1923, unacceptable sexual wishes were repressed into the "System Unconscious" unconscious due to "society's" condemnation of premarital sexual activity, and this repression created anxiety. Freud also discovered what most of us take for granted today: that dreams were symbolic and specific to the dreamer. Often, dreams give clues to unconscious conflicts, and for this reason, Freud referred to dreams as the "royal road to the Unconscious."

After several theoretical modifications, the discovery of narcissism in 1915, and the study of paranoia, masochism, and depression in 1917, Freud eventually reorganized his data into what became known as structural theory in a small book called The Ego and the Id in 1923. This new theory, which addressed the cause of neurotic symptoms %u2014 phobias, compulsions, obsessions, depressions, and "hysterical" conversions %u2014 amongst others, suggested that such problems were created by conflicts among various wishes and guilt, which produced anxiety. To handle the anxiety, the mind forgot or repressed certain conflicting thoughts. In other words, now he felt that anxiety produced repression, not the other way around.

Although criticized since its inception (See the recent criticism, below), psychoanalysis has been thriving as a research tool into childhood development (cf. the journal The Psychoanalytic Study of the Child), and has developed into a flexible, effective treatment for certain mental disturbances (see Wallerstein's (2000) Forty-Two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy). In the 1960s, Freud's early (1905) thoughts on the childhood development of female sexuality were challenged; this challenge led to the development of a variety of understandings of female sexual development, many of which modified the timing and normality of several of Freud's theories (which had been gleaned from the treatment of women with mental disturbances). Several researchers, coming together in Blum's Female Psychology, followed Karen Horney's studies of societal pressures that influence the development of women. Most contemporary North American psychoanalysts employ theories that, while based on those of Sigmund Freud, include many modifications of theory and practice developed since his death in 1939.

Masturbation was later added as another "Royal road to the Unconscious." The definitive text, covering the developmental and symbolic elements of masturbation, was prepared by Marcus and Francis (1975) in "Masturbation - from Infancy to Senescence" (Madison, CT: International Universities Press).

Today, there are approximately 35 training institutes for psychoanalysis in the United States accredited by the American Psychoanalytic Association (see www.apsa.org) which is a component organization of the International Psychoanalytical Association, and there are over 3,000 graduated psychoanalysts practicing in the United States. The International Psychoanalytical Association accredits psychoanalytic training centers throughout the rest of the world, including countries such as Serbia, France, Germany, Austria, Italy, Switzerland, and many others, as well as about six institutes directly in the U.S., and is a fast-growing organization.

Theories

The predominant psychoanalytic theories include

• Conflict Theory, which theorizes that emotional symptoms and character traits are complex solutions to intrapsychic conflict. See Brenner (2006), Psychoanalysis: Mind and Meaning, New York: Psychoanalytic Quarterly Press. This revision of Freud's structural theory (Freud, 1923, 1926) dispenses with the concepts of a fixed id, ego and superego, and instead posits unconscious and conscious conflict among wishes (dependant, controlling, sexual, and aggressive), guilt and shame, emotions (especially anxiety and depressive affect), and defensive operations that shut off from consciousness some aspect of the others. Moreover, healthy functioning (adaptive) is also determined, to a great extent, by resolutions of conflict. A major goal of modern conflict theorist analysts is to attempt to change the balance of conflict through making aspects of the less adaptive solutions (also called compromise formations) conscious so that they can be rethought, and more adaptive solutions found. Current theoreticians following Brenner's many suggestions (see especially Brenner's 1982 book, "The Mind in Conflict") include Sandor Abend, MD (Abend, Porder, & Willick, (1983), Borderline Patients: Clinical Perspectives), Jacob Arlow (Arlow and Brenner (1964), Psychoanalytic Concepts and the Structural Theory), and Jerome Blackman (2003), 101 Defenses: How the Mind Shields Itself). Conflict theory is the prevalent analytic theory taught in psychoanalytic institutes, throughout the United States, accredited by the American Psychoanalytic Association.

• Ego Psychology, which has a long history. Begun by Freud in Inhibitions, Symptoms and Anxiety (1926), the theory was refined by Hartmann, Loewenstein, and Kris in a series of papers and books from 1939 through the late 1960s. Leo Bellak picked up the work from there. This series of constructs, parallelling some of cognitive theory, includes the notions of autonomous ego functions: mental functions not dependant, at least in origin, on intrapsychic conflict. Such functions include: sensory perception, motor control, symbolic thought, logical thought, speech, abstraction, integration (synthesis), orientation, concentration, judgment about danger, reality testing, adaptive ability, executive decision-making, hygiene, and self-preservation. Freud noted inhibition as a way the mind may interfere with any of these functions to avoid painful emotions. Hartmann (1950s) pointed out that there may be delays or deficits in such functions. Frosch (1964) described differences in those people who demonstrated damage to their relationship to reality, but who seemed able to test it. Deficits in the capacity to organize thought are sometimes referred to as blocking or loose associations (Bleuler), and are characteristic of the schizophrenias. Deficits in abstraction ability and self-preservation also suggest psychosis in adults. Deficits in orientation and sensorium are often indicative of a medical illness affecting the brain (and therefore, autonomous ego functions). Deficits in certain ego functions are routinely found in severely sexually or physically abused children, where powerful affects generated throughout childhood seem to have eroded some functional development. Ego strengths, later described by Kernberg (1975), include the capacities to control oral, sexual and destructive impulses; to tolerate painful affects without falling apart; and to prevent the eruption into consciousness of bizarre symbolic fantasy. Defensive activity, which shuts certain conflictual thoughts, fantasies, and sensations out of consciousness, is also sometimes included here, although defensive operations are different from autonomous functions. Nevertheless, the term "ego defense" has become common.

• Object relations theory, which attempts to explain vicissitudes of human relationships through a study of how internal representations of self and of others are structured. The clinical problems that suggest object relations problems (usually developmental delays throughout life) include disturbances in an individual's capacity to feel warmth, empathy, trust, sense of security, identity stability, consistent emotional closeness, and stability in relationships with chosen other human beings. (It is not suggested that one should trust everyone, for example). Concepts regarding internal representations (also sometimes termed, "introjects," "self and object representations," or "internalizations of self and other") although often attributed to Melanie Klein, were actually first mentioned by Sigmund Freud in his early concepts of drive theory (1905, Three Essays on the Theory of Sexuality). Freud's 1917 paper "Mourning and Melancholia", for example, hypothesized that unresolved grief was caused by the survivor's internalized image of the deceased becoming fused with that of the survivor, and then the survivor shifting unacceptable anger toward the deceased onto the now complex self image. Vamik Volkan, in "Linking Objects and Linking Phenomena," expanded on Freud's thoughts on this, describing the syndromes of "Established pathological mourning" vs. "reactive depression" based on similar dynamics. Melanie Klein's hypotheses regarding internalizations during the first year of life, leading to paranoid and depressive positions, were later challenged by Rene Spitz (e.g., The First Year of Life, 1965), who divided the first year of life into a coenesthetic phase of the first six months, and then a diacritic phase for the second six months. Margaret Mahler (Mahler, Fine, and Bergman (1975), "The Psychological Birth of the Human Infant") and her group, first in New York, then in Philadelphia, described distinct phases and subphases of child development leading to "separation-individuation" during the first three years of life, stressing the importance of constancy of parental figures, in the face of the child's destructive aggression, to the child's internalizations, stability of affect management, and ability to develop healthy autonomy. Later developers of the theory of self and object constancy as it affects adult psychiatric problems such as psychosis and borderline states have been John Frosch, Otto Kernberg, and Salman Akhtar. Peter Blos described (1960, in a book called "On Adolescence) how similar separation-individuation struggles occur during adolescence, of course with a different outcome from the first three years of life: the teen usually, eventually, leaves the parents' house (this varies with the culture). During adolescence, Erik Erikson (1950, 1960s) described the "identity crisis," that involves identity-diffusion anxiety. In order for an adult to be able to experience "Warm-ETHICS" (warmth, empathy, trust, holding environment (Winnicott), identity, closeness, and stability) in relationships (see Blackman (2003), 101 Defenses: How the Mind Shields Itself), the teenager must resolve the problems with identity and redevelop self and object constancy.

• Structural Theory, which breaks the mind up into the id, the ego, and the superego. Actually, in German, the word for id is "es," which means "it." The word ego was coined by Freud's translators; Freud used the term, "ich" meaning "I" in English. Freud called the superego the "Über-ich." The id was designated as the repository of sexual and aggressive wishes, which Freud called "drives." The ego was composed of those forces that opposed the drives -- defensive operations. The superego was Freud's term for the conscience -- values and ideals, shame and guilt. One problem Brenner (2006) later found with this theory (see above) was that Freud also suggested that forgotten thoughts ("the repressed") were also "located" in the id. However, Freud here realized that drives could be conscious or unconscious, and that consciousness vs. unconsciousness was a quality of any mental operation or any mental conflict. Forgetting things could be done on purpose, or not. People could be aware of guilt, or not aware.

• Self psychology, which emphasizes the development of a stable sense of self through mutually empathic contacts with other humans, was developed originally by Heinz Kohut, and has been elucidated by the Ornsteins and Arnold Goldberg. Marian Tolpin explicated the need for "transmuting internalizations" (1971) during treatment, to correct what Kohut referred to as a disturbance in the "self-object" internalizations from parents.

• Lacanian psychoanalysis, which integrates psychoanalysis with semiotics and Hegelian philosophy, is popular in France.

• Feminist theory of psychoanalysis, articulated mainly by Julia Kristeva, Luce Irigaray and Bracha Ettinger, is informed both by Freud, Lacan and the Object relations theory.

• Analytical psychology, which has a more spiritual approach, founded by Carl Jung

• Interpersonal psychoanalysis, which accents the nuances of interpersonal interactions, was first introduced by Harry Stack Sullivan, MD, and developed further by Frieda Fromm-Reichmann. It is the primary theory, still taught, at the William Alanson White Center.

• Relational psychoanalysis, which combines interpersonal psychoanalysis with object-relations theory as critical for mental health, was introduced by Stephen Mitchell. Relational psychoanalysis emphasizes how the individual's personality is shaped by both real and imagined relationships with others, and how these relationship patterns are re-enacted in the interactions between analyst and patient. Fonagy and Target, in London, have propounded their view of the necessity of helping certain detached, isolated patients, develop the capacity for "mentalization" associated with thinking about relationships and themselves.

• Modern psychoanalysis, a body of theoretical and clinical knowledge developed by Hyman Spotnitz and his colleagues, extended Freud's theories so as to make them applicable to the full spectrum of emotional disorders. Modern psychoanalytic interventions are primarily intended to provide an emotional-maturational communication to the patient, rather than to promote intellectual insight.

Although these theoretical "schools" differ, most of them continue to stress the strong influence of unconscious elements affecting people's mental lives. There has also been considerable work done on consolidating elements of conflicting theory (cf. the work of Theodore Dorpat, B. Killingmo, and S. Akhtar). As in all fields of medicine (for example, [1]}, there are some persistent conflicts regarding specific causes of some syndromes, and disputes regarding the best treatment techniques.

Today psychoanalytic ideas are embedded in the culture, especially in childcare, education, literary criticism, and in psychiatry, particularly medical and non-medical psychotherapy. Though there is a mainstream of evolved analytic ideas, there are groups who more specifically follow the precepts of one or more of the later theoreticians. It also plays a role in literary analysis. See Archetypal literary criticism.

Psychopathology (mental disturbances)

The various psychoses involve deficits in the autonomous ego functions (see above) of integration (organization) of thought, in abstraction ability, in relationship to reality and in reality testing. In depressions with psychotic features, the self-preservation function may also be damaged (sometimes by overwhelming depressive affect). Because of the integrative deficits (often causing what general psychiatrists call "loose associations," "blocking," "flight of ideas," "verbigeration," and "thought withdrawal"), the development of self and object representations is also impaired. Clinically, therefore, psychotic individuals manifest limitations in warmth, empathy, trust, identity, closeness and/or stability in relationships (due to problems with self-object fusion anxiety) as well.

In patients whose autonomous ego functions are more intact, but who still show problems with object relations, the diagnosis often falls into the category known as "borderline." Borderline patients also show deficits, often in controlling impulses, affects, or fantasies -- but their ability to test reality remains more or less intact.

Those adults who do not experience guilt and shame, and who indulge in criminal behavior, are usually diagnosed as psychopaths, or, using DSM-IV-TR, antisocial personality disorder.

Panic, phobias, conversions, obsessions, compulsions and depressions (analysts call these "neurotic symptoms") are not usually caused by deficits in functions. Instead, they are caused by intrapsychic conflicts. The conflicts are generally among sexual and hostile-aggressive wishes, guilt and shame, and reality factors. The conflicts may be conscious or unconscious, but create anxiety, depressive affect, and anger. Finally, the various elements are managed by defensive operations -- essentially shut-off brain mechanisms that make people unaware of that element of conflict. "Repression" is the term given to the mechanism that shuts thoughts out of consciousness. "Isolation of affect" is the term used for the mechanism that shuts sensations out of consciousness. Neurotic symptoms may occur with or without deficits in ego functions, object relations, and ego strengths. Therefore, it is not uncommon to encounter obsessive-compulsive schizophrenics, panic patients who also suffer with borderline personality disorder, etc.

Furthermore, we know that many adult problems can trace their origins to unresolved conflicts from certain phases of childhood and adolescence. Freud, based on the data gathered from his patients early in his career, suspected that neurotic disturbances occurred when children were sexually abused in childhood (the so-called seduction theory). Later, Freud came to realize that, although child abuse occurs, that not all neurotic symptoms were associated with this. He realized that neurotic people often had unconscious conflicts that involved incestuous fantasies deriving from different stages of development. He found the stage from about three to six years of age (preschool years, today called the "first genital stage") to be filled with fantasies about marriage with both parents. Although arguments were generated in turn-of-the-(20th)century Vienna about whether adult seduction of children was the basis of neurotic illness, there is virtually no argument about this problem in the 21st century.

Many psychoanalysts who work with children have studied the actual effects of child abuse, which include ego and object relations deficits and severe neurotic conflicts. Much research has been done on these types of trauma in childhood, and the adult sequelae of those. On the other hand, many adults with symptom neuroses and character pathology have no history of childhood sexual or physical abuse.

In studying the childhood factors that start neurotic symptom development, Freud found a constellation of factors that, for literary reasons, he termed the Oedipus complex (based on the play by Sophocles, Oedipus Rex, where the protagonist unwittingly kills his father Laius and marries his mother Jocasta). The shorthand term, "oedipal," (later explicated by Joseph Sandler, 1960, in "On the Concept Superego" and modified by Charles Brenner (1982) in "The Mind in Conflict") refers to the powerful attachments that children make to their parents in the preschool years. These attachments involve fantasies of marriage to either (or both) parent, and, therefore, competitive fantasies toward either (or both) parents. Humberto Nagera (1975) has been particularly helpful in clarifying many of the complexities of the child through these years.

The terms 'positive' and 'negative' oedipal conflicts have been attached to the heterosexual and homosexual aspects, respectively. Both seem to occur in development of most children. Eventually, the developing child's concessions to reality (that they will neither marry one parent nor eliminate the other) lead to identifications with parental values. These identifications generally create a new set of mental operations regarding values and guilt, subsumed under the term "superego." Besides superego development, children "resolve" their preschool oedipal conflicts through channeling wishes into something their parents approve of ("sublimations") and the development, during the school-age years ("latency") of age-appropriate obsessive-compulsive defensive maneuvers (rules, repetitive games).

When there is disturbance in the family during the first genital phase (such as death of a parent or divorce), unusual magnification of anxieties in the child may occur. This sets the stage for problems during latency and adolescence. Later in life, under certain circumstances, a recrudescence of symptoms may occur during periods that are either stressful or symbolic -- such as marriage, having children, or graduating from school.

Controversies regarding infantile sexuality and the oedipus complex are prevalent within and without psychoanalytic circles.

Indications and contraindications for analytic treatment

Using the various analytic theories to assess mental problems, several particular constellations of problems are particularly suited for analytic techniques (see below) whereas other problems respond better to medicines and different interpersonal interventions.

To be treated with psychoanalysis, whatever the presenting problem, the person requesting help must demonstrate

1. good capacity to organize thought (integrative function)
2. good abstraction ability
3. reasonable ability to observe self and others
4. some capacity for trust and empathy
5. some ability to control emotion and urges, and
6. good contact with reality (excludes most psychotic patients)
7. some guilt and shame (excludes most criminals)
8. reasonable self-preservation ability (excludes severely suicidal patients)

If any of the above are faulty, then modifications of techniques, or completely different treatment approaches, must be instituted. The more there are deficits of serious magnitude in any of the above mental operations (1-8), the more psychoanalysis as treatment is contraindicated, and the more medication and supportive approaches are indicated. In non-psychotic first-degree criminals, any treatment is often contraindicated.

The problems treatable with analysis include: phobias, conversions, compulsions, obsessions, anxiety attacks, depressions, sexual dysfunctions, a wide variety of relationship problems (dating and marital strife, e.g.), and a wide variety of character problems (e.g., painful shyness, meanness, obnoxiousness, workaholism, hyperseductiveness, hyperemotionality, hyperfastidiousness). The fact that many of such patients also demonstrate deficits in numbers 1-8 above makes diagnosis and treatment selection difficult.

Technique

The basic method of psychoanalysis is interpretation of the analysand'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).

Freud's patients would lie on this couch during psychoanalysis

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 (1995), 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 best summarized by Allan Compton, MD, as comprising:

1. instructions (telling the patient to try to say what's on their mind, including interferences)
2. exploration (asking questions)
3. clarification (rephrasing and summarizing what the patient has been describing)
4. confrontation (bringing an aspect of functioning, usually a defense, to the patient's attention)
5. dynamic interpretation (explaining how being too nice guards against guilt, e.g. - defense vs. affect)
6. genetic interpretation (explaining how a past event is influencing the present)
7. resistance interpretation (showing the patient how they are avoiding their problems)
8. transference interpretation (showing the patient ways old conflicts arise in current relationships, including that with the analyst)
9. dream interpretation (obtaining the patient's thoughts about their dreams and connecting this with their current problems)
10. reconstruction (estimating what may have happened in the past that created some current day difficulty)

Clearly, these techniques are primarily based on conflict theory (see above). As object relations theory evolved, supplemented by the work of Bowlby, Ainsorth, 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:

1. expressing an experienced empathic attunement to the patient
2. expressing a certain dosage of warmth
3. exposing a bit of the analyst's personal life or attitudes to the patient
4. allowing the patient autonomy in the form of disagreement with the analyst (cf. I.H. Paul, Letters to Simon.)
5. explanations of the motivations of others which the patient misperceives

Finally, 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:

1. discussions of reality
2. encouragement to stay alive (including hospitalization)
3. psychotropic medicines to relieve overwhelming depressive affect
4. psychotropic medicines to relieve overwhelming fantasies (hallucinations and delusions)
5. advice about the meanings of things (to counter abstraction failures)

The notion of the "silent analyst" has been made into negative propaganda against analysis. Actually, the analyst listens in a special way (see Arlow's paper on "The Genesis of Interpretation"). Much active intervention is necessary by the analyst to interpret resistances, defenses creating pathology, and fantasies that are being displaced into the current day inappropriately. Silence and non-responsiveness was actually a technique promulgated by Carl Rogers, in his development of so-called "Client Centered Therapy" -- and 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.

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.

Training

Psychoanalytic training in the United States, in most locations, involves three facets:

1. Personal analytic treatment for the trainee, conducted confidentially, with no report to the Education Committee of the Analytic Training Institute.
2. Approximately 600 hours of class instruction, with a standard curriculum, over a four-year period. Classes are often a few hours per week, or for a full day or two every other weekend during the academic year; this varies with the institute.
3. Supervision once per week, with a senior analyst, on each analytic treatment case the trainee has. The minimum number of cases varies between institutes, often two to four cases. Male and female cases are required. Supervision must go on for at least a few years on one or more cases. Supervision is done in the supervisor's office, where the trainee presents material from the analytic work that week, examines the unconscious conflicts with the supervisor, and learns, discusses, and is advised about technique.

Psychoanalytic Training Centers in the United States have been accredited by special committees of the American Psychoanalytic Association or the International Psychoanalytical Association. Because of theoretical differences, other institutes have arisen, as well, which belong to other organizations such as the American Academy of Psychoanalysis and Dynamic Psychotherapy, and the National Association for the Advancement of Psychoanalysis. At most psychoanalytic institutes in the United States, qualifications for entry include a terminal degree in a mental health field, such as Ph.D., C.S.W., or M.D. A few institutes restrict applicants to those already holding an M.D. or Ph.D., and one institute in Southern California confers a Ph.D. or Psy.D. in psychoanalysis upon graduation, which involves completion of the necessary requirements for the state boards that confer that doctoral degree. In many institutes in Europe and Latin America, the admission for training does not necessarily require a license-bearing preliminary degree.^{[citation needed]}

Some psychoanalytic training has been set up as a post-doctoral fellowship in university settings, such as at Duke University, Yale University, New York University, and Columbia University. Other psychoanalytic institutes may not be directly associated with universities, but the faculty at those institutes usually hold contemporaneous faculty positions with psychology Ph.D. programs and/or with Medical School psychiatry residency programs.

Psychoanalysis was limited to those "in the know" from the early 1920s (when A.A. Brill began the New York Psychoanalytic Institute) through the end of World War II, although the idea that repression of sexual urges could make you mentally ill (Freud's first, discarded theory) proved popular with college students in the 1920s -- who used the theory to argue with their conservative parents. During those early years, Andrew Carnegie was perhaps one of the most famous patients who benefited; he later made his gratitude public by endowing a psychoanalytic fund in Pittsburgh.

Psychoanalysis became popular post-war, as many celebrities found it useful -- such as Steve Allen, Jayne Meadows, and Art Buchwald. Psychoanalytic treatment became somewhat less popular during the 1980s and early 1990s. Circa 1986, when insurance companies decimated health insurance coverage for all mental illnesses (in part due to corrupt practices in some for-profit hospitals), people for whom psychoanalytic treatment was indicated were increasingly unable to afford it. Gradually, as psychiatry departments became more dependent on grants from pharmaceutical companies, chairs of Psychiatry Departments in the nation's medical schools tended to come from backgrounds involving pharmacological research -- not from backgrounds involving analytic training. Interestingly, psychoanalytic institutes have experienced an increase in the number of applicants in recent years, but, not surprisingly, about 70-80% of incoming students are non-MDs.^[2]

Efficacy and empirical research

Over a hundred years of case reports and studies in the journal Modern Psychoanalysis, the Psychoanalytic Quarterly, the International Journal of Psychoanalysis and the Journal of the American Psychoanalytic Association demonstrate the efficacy of analysis in cases of neurosis and character or personality problems. Psychoanalysis modified by object relations techniques has been shown to be effective in many cases of ingrained problems of intimacy and relationship (cf. the many books of Otto Kernberg). As a therapeutic treatment, psychoanalytic techniques may be useful in a one-session consultation (see Blackman, J. (1994), Psychodynamic Technique during Ungent Consultation Interviews, Journal Psychotherapy Practice & Research). Psychoanalytic treatment, in other situations, may run from about a year to many years, depending on the severity and complexity of the pathology.

Psychoanalytic theory has, from its inception, been the subject of criticism and controversy. Freud remarked on this early in his career, when other physicians in Vienna ostracized him for his findings that hysterical conversion symptoms were not limited to women. Challenges to analytic theory began with Otto Rank and Adler (turn of the 20th century), continued with behaviorists (e.g. Wolpe) into the 1940s and '50s, and have persisted. Criticisms come from those who object the notion that there are mechanisms, thoughts or feelings in the mind that could be unconscious. Criticisms also have been leveled against the discovery of "infantile sexuality" (the recognition that children between ages two and six imagine things about procreation). Criticisms of theory have led to opposing analytic theories, such as the work of Fairbairn, Balint, and Bowlby. In the past 30 years or so, the criticisms have centered on the issue of empirical verification,^[3] in spite of many empirical, prospective research studies that have been empirically validated (e.g., See the studies of Barbara Milrod, at Cornell University Medical School, et al.).

Psychoanalysis has been thriving as a research tool into childhood development (cf. the journal The Psychoanalytic Study of the Child), and has developed into a flexible, effective treatment for certain mental disturbances (see Wallerstein's (2000) Forty-Two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy). In the 1960s, Freud's early (1905) thoughts on the childhood development of female sexuality were challenged; this challenge led to major research in the 1970s and 80s, and then to a reformulation of female sexual development that corrected some of Freud's concepts.^[4]

Analysis of previous randomized controlled trials has suggested that psychoanalytic treatment is effective in specific psychiatric disorders. [2]. Empirical research on the efficacy of psychoanalysis and psychoanalytic psychotherapy has also become prominent among psychoanalytic researchers.

Research on psychodynamic treatment of some populations shows mixed results. Research by analysts such as Bertram Karon and colleagues at Michigan State University had suggested that when trained properly, psychodynamic therapists can be effective with schizophrenic patients. More recent research casts doubt on these claims. The Schizophrenia Patient Outcomes Research Team (PORT) report argues in its Recommendation 22 against the use of psychodynamic therapy in cases of schizophrenia, noting that more trials are necessary to verify its effectiveness. However, the PORT recommendation is based on the opinions of clinicians rather than on empirical data, and empirical data exist that contradict this recommendation (link to abstract). A review of current medical literature in The Cochrane%2