The psychoanalyst uses the principle of psychic determinism to discover the unconscious ideas and conflicts of the patient that originated in the past, thus helping the patient to become free of the neurotic compulsion to repeat the past, and instead to be able to live in the present (Covington, 2001). The basic technique of psychoanalysis is free association, which requires the patient "to say whatever came into his head, while ceasing to give any conscious direction to his thoughts" (Freud, 1935/1963a, p. 75). Suspension of conscious control allows the forces of the unconscious, which are usually obscured by the consciousness, to be observed directing thoughts and memories. In addition to the interview, some clinicians also use psychological tests to guide their diagnosis (Jaffe, 1992).
The emergence of buried feelings from the unconscious is called catharsis. These feelings, including fear and grief, often accompany the recall of forgotten memories. Like the removal of infectious material when a wound is lanced, catharsis frees the unconscious of troublesome repressions.
Psychoanalytic treatment produces insight, that is, understanding of true motives, which are unconscious conflicts. To be therapeutic, insight must be accompanied by emotional awareness. While the insight into unconscious motivations, even if accompanied by emotional catharsis, is a major step toward overcoming the symptoms produced by the unconscious, it does not provide a magical, once-and-for-all cure. In addition to this dramatic recall, modern psychoanalysis recognizes that unconscious conflicts must be confronted again and again in a psychoanalytic treatment. The patient must "work through" the conflict, discovering the many circumstances that have been influenced by it and essentially reconstructing personality to replace these unconscious irrational determinants with more reasonable and mature motivations.
A major phenomenon in psychoanalytic treatment is transference. During the course of psychoanalytic treatment, the patient develops a relationship to the therapist based on unconscious projections from earlier life. The patient perceives the therapist erroneously and experiences emotions that were repressed when felt toward earlier significant others. It is common, for example, for a female patient to "fall in love with" her male analyst because of transference of the love she felt for her father during childhood. Negative as well as positive emotions occur. Transference is, strangely enough, desirable, according to psychoanalysts. It permits the earlier, unresolved issues to be present in the analytic session, where they can be resolved. More problematic are the analyst's emotional reactions to the patient, termed countertransference, which may interfere with treatment because they represent the analyst's unresolved complexes.
In his day, Freud's theory was a force for the humane treatment of the mentally ill because it interpreted their disorders as the consequence of disease (the medical model) rather than of moral failure. Today, critics argue that the medical model has adverse implications. It treats people as passive victims of pathological forces, undermining their active effort and responsibility for their own psychological well-being. An outspoke critic of the medical model, Thomas Szasz argues that the mental illness model ignores the truth that even people who have abnormal biological or unconscious states can, like others, make moral choices; to theorize otherwise is to ignore the evidence of science and to deprive them of their humanity (Szasz, 2001). The medical model tends to place the wisdom of the physician over the experience of the patient and is insensitive to the role of social factors in causing psychopathology. How ironic that Freud, whose theory began with the premise that the experience of patients must be taken seriously, should be criticized for such a shortcoming.
There has been considerable effort in recent years to investigate the effectiveness of various modes of psychotherapy (Westen & Morrison, 2001). Therapy comes in many forms today, and psychoanalytic treatment is considerably more time-consuming and expensive than alternative modes of treatment. A typical analysis may take three to seven years, three sessions each week. Some alternate treatments may take only a few weeks. Is psychoanalysis more effective, justifying the extra cost and commitment? There has been much skepticism even about Freud's own therapeutic effectiveness (e.g., Ellenberger, 1972; Mahony, 1986). Evidence for analytic therapy's effectiveness is mixed, favoring psychoanalysis for psychosomatic disorders (Fisher & Greenberg, 1977), but not for anxiety and phobias (Goldfried, Greenberg, & Marmar, 1990) or depression (Westen & Morrison, 2001). We should be cautious, though, since it isn't easy to evaluate therapy effectiveness, especially to compare different approaches. The requirements of data collection may constrain therapists from their usual procedures (Busch et al., 2001). Some research indicates that, if patients are assessed after a longer time period, the advantage of psychodynamic therapy increases (Blomberg, Lazar, & Sandell, 2001), which makes sense if we grant that this approach aims at more fundamental personality change. However, investigation of the effectiveness of therapy is just beginning, and until methodological difficulties have been addressed and more studies conducted, using diverse methodologies, we really don't know scientifically what works and what doesn't (Westen & Morrison, 2001).
Besides outcome studies, researchers study the process of psychoanalytic therapy, using clinicians' notes and even recordings of sessions to understand what particular techniques work (e.g., Jones & Windholz, 1990; Wallerstein & Sampson, 1971; Weiss, 1988; Wölpe & Rachman, I960). These systematic studies of psychotherapy suggest that insight is less important to successful treatment than psychoanalytic theory predicts (Wallerstein, 1989)- Such studies promise to improve therapy, whether or not more global empirical validation of treatment outcomes is feasible (Strupp, 2001).
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