Psychoanalysis

The English school of psychoanalysis emerged under the leadership of Melanie Klein. The school’s theories were derived from observations made in the psychoanalysis of children and have a strong influence on contemporary practice, particularly in Europe and South America. The theories are based on the importance of primitive fantasies of loss (the “depressive position”) and persecution (the “paranoid position”). The principal source of anxiety is said to arise from the threat posed by the “death instinct”. In the paranoid position, the ego’s defence consists of projecting the dangerous internal object on to some external representative, which is treated as a genuine threat emanating from the external world. In the depressive position, the threatening object is introjected and treated in fantasy as concretely retained within the person. Symptoms of depression and hypochondriasis result. Although considerable doubt exists that such complex unconscious fantasies operate in the minds of infants, these observations have been of importance to the psychology and psychiatry of unconscious fantasies, paranoid delusions, and theories dealing with early object relations.

Psychoanalytic theory continues to be studied and modified. Important contributions have come from, in the 1930s, Heinz Hartman, who formulated concepts of the adaptive function of the ego; in the 1950s, from Anna Freud, who worked primarily with children; and from David Rapaport, who attempted to integrate psychoanalytic theory with broader psychological principles.

Therapists come from all backgrounds, often paramedical. Training is through an institute of psychoanalysis and takes several years. Initially, trainees are required to undergo their own analysis usually for at least a year before they take part in seminars. In turn they begin to work as therapists under the supervision of a more experienced psychoanalyst. Psychoanalysis is not widely available in National Health Service practice in the United Kingdom. Because it can be time consuming, expensive, and demanding of the client, it should not be undertaken lightly.

Clients are ideally assessed for their suitability for psychoanalysis by an analyst other than the therapist they will ultimately see. The client must have an appropriate disorder, be psychologically minded, able to reflect on themselves, and be committed to the process. They should not be actively suicidal and generally speaking not have severe psychotic mental illness (seeMental Disorders).

For this reason psychoanalytic psychotherapy is best suited to phobic disorders, more chronic depressive disorders, certain personality disorders, and eating disorders.

The process begins with assessment and the allocation of a therapist. Sessions are usually for a least 50 minutes, four times a week. Much importance is attached to the consistency of timing and venue, which represent boundaries that are important in the therapeutic experience. The therapist should explain these rules to the client, who is encouraged to talk freely about any issues that come to mind. The therapist listens carefully to what is said, and by detecting themes and sequences within the narrative begins to understand the underlying unconscious processes. The client is helped to link current feelings to past experience by way of interpretations offered by the therapist. This process is dynamic and changes over time.

After the initial or opening phase, the client begins to develop feelings for the therapist, which are in fact representative of previous feelings towards other important figures in the client’s life. This is termed transference. Through the transference relationship the analyst can discover earlier suppressed conflicts, wishes, and fantasies, and by interpretation help the client re-establish a healthier dynamic equilibrium. This process is revisited many times during the therapy, a process known as “working through”. In the final stage of treatment, the therapist aims to resolve the neurotic attachment the client has formed: this is the resolution of transference. At each stage in the process, the dynamic changes that occur provide an opportunity for hitherto hidden thoughts, feelings, and impulses to emerge, which help the therapist understand the client. Overall treatment may last months or years.