MODULE 7: PSYCHOANALYTIC THERAPY

This module will discuss the nature and elements of psychoanalytic therapy, also known as
Talk Therapy. It will focus on how to uncover the unconscious content of a client's psyche in
order to alleviate psychic tension.

ENGAGE

Let’s have a short recap of some of Freud’s important key concepts!

TOPOGRAPHICAL MODEL

Conscious
Considered to be the “tip of the iceberg” or, as Freud would say, a thin slice of
the human mind.
Preconscious
Contains all memories and information that can be brought to the conscious
Unconscious
Contains all information, experiences, drives and other repressed materials. This
portion is considered to be the least accessible.

STRUCTUAL MODEL OF PERSONALITY

Id (Pleasure Principle)
It is considered as the original system of personality. At birth, the only structure present
is the id. It contains our drives and impulses; biological component
Ego (Reality Principle)
The structure that is in contact with reality. Moreover, it is the one that
governs, controls and regulates personality.
Superego (Conscience, Ego-ideal)
It is considered as the judicial branch of personality. It includes the person’s sense
of what is right and wrong. It inhibits the id’s impulses, and persuades the ego to
put morals above anything else and to strive for perfection.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
1
 In Freud’s theory, a “stable personality” is where there is balance, and the ego is able to
mediate the demands of the id, superego and reality.

Super-
Id
ego

“Stable personality”
Ego

However, if the ego fails to mediate the demands of the three, this may lead to several
outcomes.

May lead to restricted personality or

behaviors (eg. OCD, OCPD)

Ego

May lead to pleasure-seeking

Ego personality or behavior

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
2
 EXPLORE

Personal Reflection

Some clients come for help because they see themselves

repeating past mistakes over and over again –
choosing partners who have problems with addictions or
working for a mean boss in every job they take. How do
you see your own history repeating itself in some
aspect of your life? What are the ongoing personal
struggles that you have faced? These could involve
difficulties with intimacy, authority figures, or poor self-
esteem, among others.

What are some possible sources in your early life that

could be responsible for these personal struggles? What have you suffered previously that
continues to plague you today?

EXPLAIN: PSYCHOANALYTIC THERAPY APPROACH

Goal of Therapy

The goal of psychoanalytic therapy is to help the client achieve insight. In a more
elaborated term, it aims to help the client uncover the resistance that opposes self-
knowledge, and to make the unconscious conscious. Uncovering the unconscious
determinants of irrational thoughts, feelings and behavior may lead to confrontation
and understanding of these determinants, which in turn, may lead to the
disappearance of neurotic symptoms and defense mechanisms.

Psychoanalysis directs itself to the maladaptive neurotic behavioral problems. The

development of neurosis consists of:

- Precipitating factors (eg. Harsh childhood experience)

- Failure in the solution of actual problems which may lead to regression.
- In turn, this may revive the primary conflict, followed by the futile struggle to
solve them.
- Substitute gratification and self-punishment expressed in symptoms
- Resulting in secondary conflict

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
3
 - These will further result to the impoverishment of the ego. To protect itself, it will
turn to defense mechanisms.

Therefore, neurosis is seen as the failure of the ego to mediate the demands of the id,
superego and the environment (reality). This failure, then, pushed the ego to resort to
defense mechanisms. That’s why, as mentioned, psychoanalysis aims to help the client to
extend the integrative capacity of the ego over the impulses that have been repressed. This
will result in a greater adaptability and flexibility of the client. If the ego has been
strengthened, the client’s behavior will be based more on reality (of course, with
proper consideration of other factors) and less on the instinctual cravings and/or irrational
guilt.

Therapeutic Processes

Therapist’s function and roles

In classical psychoanalysis, the therapist assumes a neutral stance (sometimes referred to
as the blank-screen approach). This reverses the process of repression. The therapist
reacts differently from the way the client’s parents reacted. Remaining in a neutral
stance sends the client a message that the therapist is not judging and evaluating him/her.
Through this, the client learns that the therapist does not condemn him, and, as a result,
the client will be able to freely express his/her thoughts, feelings and desires. Thus, the
unconscious becomes conscious as an indispensable part of the therapy.

Since a sense of neutrality must remain, therapists must avoid self-disclosure. This is to foster
a transference relationship, in which the client will make projections onto them. The
repressed attitudes of the client are directed towards the therapist. That is, the attitudes
that are originally directed towards the parents are transferred to the therapist. This
emotional experience is an important aspect of the process. This provides an opportunity
for the ego to confront the situations in a new setting, with a person who does not react in
a way as the parents did. This leads to the client’s realization of how his/her reactions
are no longer relevant or suited to the present.

The recognition of the inappropriateness of his behavior is not only an intellectual insight,
but a corrective emotional reaction. This experience is the central therapeutic agent in
the process of change -- it consists of a series of corrective emotional experiences.

These 3 factors: a) emotional abreaction (expression of repressed emotions), b)

intellectual insight, and c) appearance of repressed memories are interrelated and
interdependent. Without emotional abreaction, insight is ineffective. Recollection of
repressed memories is also important because it is a part of insight.

If therapy is to produce change, then, transference (discussed on the latter section) must
be worked through. The working-through process consists of repetitive and elaborate
exploration of the unconscious (drives, motives, defense mechanisms, etc.), which may
have its roots in early childhood.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
4
 Implementation of the Psychoanalytic process
Orthodox (Traditional) Psychoanalysis insists of
an intense frequency of 50 minutes of
analytic sessions with a minimum of four
sessions a week. The frequency of the
sessions propels analytic work because that
which is begun in one session is quickly
followed up in the next as the stream of
associations continues to flow. Long
intervals between sessions tend to thicken
the resistance and allow for repression of
material already uncovered.

Newer trends in psychoanalytic therapy are

not at all enthusiastic about this high
frequency of sessions. They claim that too frequent sessions tend to gratify the client’s
dependency needs more than is desirable or reduce his emotional participation since
the sessions become routine. The optimum frequency varies from case to case according to
the intensity of the impulses to be built up to the point at which the client can become
aware of them. Moreover, long and deep regressions should be avoided as they are not
always needed in order to reach the objective of the therapy and in order to lessen the
burden (financial and otherwise) of the client and the therapist. “The primary concern in
therapy is not the recovery of the past, but the discovery of solutions for present
problems.” – C.H. Patterson
In the classical analytic procedure, the client reclines on a couch and is made as
comfortable as possible. The therapist sits out of direct line of vision of the client. In
this arrangement, the client is better able to fantasize and to regress, to project and
displace upon the therapist feelings and attitudes towards figures from the past, that
is, to form transference. The supine position also minimizes motor activity, thus
encouraging verbalization rather than action. Verbalization not only facilitates
remembering, but it is also conducive to the establishment of higher levels of object
relations. Acting out on the other hand, blocks remembering by bypassing the ego, thus
lessening opportunity of insight. It permits temporary discharge without therapeutic gain,
whereas verbalization is instrumental to ego-building.

At the outset, the therapist gives the client some understanding of the general method
of procedure and of the purpose and aims of the therapy. The client is acquainted with
the fact that some of his behaviors and attitudes may be dependent upon emotional
factors of which he is unaware and that the task of the therapist is to trace back these
associations to unconscious motivations. As these unconscious strivings are elevated to the
conscious plane and interpreted and understood, they may be assimilated into the
personality and lose their potency for disturbing his integrated activity.

Therapeutic Techniques and Procedure

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
5
 The therapist regards the symptoms of neurosis and maladaptive behaviors as
manifestations of the conflict between the id, ego, superego and the demands of reality.
In other words, the symptom indicates an unconscious conflict that needs resolution.

The psychoanalytic process stresses maintaining a particular framework aimed at

accomplishing the goals of this type of therapy. Maintaining the analytic framework refers
to a whole range of procedural and stylistic factors, such as the therapist maintaining
neutrality and objectivity, regularity and consistency of meeting, and starting and ending of
sessions on time.
Over the years, numerous techniques have been developed to achieve the goal of
therapy. Nonetheless, the basic emphasis on the dissolution of repressions through the re-
analysis of past experience remains. Think of it as having various routes, but leading to
the same destination. Despite the numerous techniques that exist, all are made to achieve
the same goal.

The following sections will discuss some of the techniques commonly used.

✔ Free Association
A cardinal rule is let the client say anything and
everything that comes to mind. The client is to put
all his thoughts, memories, and feelings into
words. It is up to the client to choose whatever
topic or subject matter he wants to talk about.
However, the client is instructed to report
everything that passes through his mind,
irrespective of whether he thinks it is relevant or
important. In fact, he is specifically interdicted
from trying to construct a consistent and logical
narrative as he might under
ordinary circumstances and instead is told to follow his thoughts wherever they may lead,
even if they do not seem to make any sense.

Allowing the client to talk about anything will eventually lead to the repressed memories
and emotions. The therapist assumes that one association will lead to another. As the
process continues, one gets closer to the unconscious thoughts and urges. Some
associations may not be clear, or may appear irrelevant. However, over the course of
therapy, patterns of associations will start to emerge, and the therapist can integrate
these to “create a complete picture”.

It is important to keep in mind that a client’s thoughts are influenced by four determinants

✔ External stimuli
✔ Visceral-somatic stimuli
✔ Conscious intentions (for example, what he wants to say, which requires
the suppression of other thoughts that might interfere)

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
6
 ✔ Unconscious or repressed ideas that seek discharge and interfere with conscious
intentions.
As the psychotherapist, we are interested in exposing this last group (unconscious or
repressed). Hence, we try to minimize the effects of the other three as much as possible, in
order that the latter may become more recognizable. External stimuli during the
psychoanalytic hour are therefore reduced to a minimum and are held relatively constant.
Internal physical distress cannot be controlled, but when present, it interferes with the
analytical work. The main object of the fundamental rule is to eliminate the client’s
conscious intentions and goals. When these are excluded, presumably what determines
the client’s productions are the remaining unconscious and irrational impulses from within.

✔ Resistance

As the client proceeds with his free associations, there will be

many indications that he is unable to bring forward important
material. Resistance is the inability to remember any
important past events or to talk about anxiety-charged subjects.

Resistance can be seen as a defense against anxiety. Resistance

operates in the therapy to prevent the client and therapist
from succeeding in gaining insight. An assumption of analytic
treatment is that clients will want both: to change and gain
insight, and at the same time, to remain in the old world and
cling to the familiar (and unhealthy) pattern.

Resistance can come in various forms. Clients who begin to

talk less, have longer pauses, or those who report that their minds are “blank” are
manifestations of resistance. Resistance may also be in a form wherein the client will
endlessly talk about the same thing over and over again. The handling of resistances
calls for the greatest skill and experience in the therapist and attention to resistances take
precedence over all other therapeutic maneuvers.

One thing to know about resistance is that it is not something to be overcome. The
therapist must recognize and work with resistance. It is crucial that the therapist
respects the resistance, and assists the client in working with their defenses. When
handled properly, resistance may be extremely helpful in further understanding the client.

✔ Dream Analysis

Another technique is the analysis of dreams. Dreams are believed to be manifestations

of the unconscious. It is the impulses and desires of the client disguised as symbols.
Dreams are

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
7
 seen as symbolic wish fulfillment, that provide important
clues to childhood wishes and feelings.

Dreams have 2 main components: a) Latent,

which consists of hidden, symbolic and/or unconscious
motives, and fears; b) Manifest, which are objects that
appear in the dream
Many things are represented by their opposites. The
dream is the result of a compromise between two
opposing forces –the wish to express a desire or
relieve tension and the tendency to reject the desire.
Painful dreams, from which the dreamer awakes in
terror,
represent the failure of the dream work to disguise the objectionable content sufficiently, or
are the result of a guilty conscience.

In order to analyze and uncover the meaning of the client’s dreams, the client will engage
in free association with regard to the manifest content. With the assistance of the therapist,
the latent elements are discovered. The free association and the therapeutic situation
lessen the client’s unconscious censorship, so that the pressure of the repressed wish
breaks through. Certain dream elements are common symbols of universal human
experience.

However, certain problems may arise when conducting dream analysis. For instance, while
it’s true that free association will help, the meaning of one dream will not always be
apparent and cannot simply be uncovered via free association. The real meaning of the
dream may only become apparent from the analysis of a whole series of the dreams.
Another potential problem is the client’s tendency to distort the manifest content. Not only
that the therapist must exert extra effort in finding the symbolic meaning, there is also the
need to handle the client’s defenses that interfere with the process.

✔ Transference

Transference is unavoidable in the process.

Transference manifest itself when the client projects
on to the therapists everything that is originally for
the parents (or any significant figure from the
client’s childhood). During transference, both
fantasies and real experiences will be reenacted
and emotions of love, hate, fear, anxiety, and
resentment will be projected on the therapist.

Transference is valuable since it provides the client

a space to re-experience a variety of feelings that would otherwise be inaccessible.
Moreover, it provides the therapist an opportunity to interpret the transference that would
further help to gain a better understanding of the client.

Transference can either be positive or negative, depending on what is being projected.

When the emotions directed toward the therapist are those of affection and dependence,
Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
8
 the transference is positive. Positive transference is often responsible for what appears to
be rapid improvement at the beginning stages of therapy. In contrast, if a hostile
attitude is dominant, the transference is negative.

However, it is important to keep in mind that not all feelings that the client is expressing
are manifestations of transference. Many of these may be based on reality, not on the past.
Not all positive responses, such as liking the therapist, should be labeled as positive
transference. Likewise, a client’s anger toward the therapist may be because of
something that the therapist did or said that may have offended the client; it is a
mistake to label all negative feelings as negative transference.

Like resistance, transference can take many forms. It may be reflected in the client’s
comments about the therapist’s clothing, talking, or even the layout of the counseling
room. It may take in the form of a direct comment of dislike, anger or an attack on the
therapist's efficacy. It may also contain direct comments of admiration or love. Regardless
of the form and content of the comment, it is important to remember that these do not
reflect realities, but are rooted in the client’s unresolved issues during childhood.

Handling transference is an important skill that a therapist should learn. A therapist must
be able to meet the transference boldly but treat it as something unreal. Success in the
analysis depends upon the passive direction of the transference to understanding the
client’s resistance.

It is important to recognize that the transference, which is the heart of the psycho-analytic
method, is not entirely a one-sided affair. The therapist needs to constantly be on guard for
indications of counter-transference.

Thought Questions

Bring to mind the image of someone you don’t like

very much, someone who really gets underneath your
skin. This may be a person who once betrayed you,
someone who rejected you, or someone who has been
repeatedly abusive toward you.

Now imagine that a new client comes in to see you who

bears a striking resemblance to your nemesis, either in
appearance or mannerisms. How do you suppose you would feel working with this
individual who reminds you of another person whom you despise? Do you think there is
any way possible that your strong feelings would not affect your relationship with this
client?

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
9
 ✔ Interpretation
As gradually unconscious elements surface
through free associations, resistances, dream
content and transference, the therapist tries to
deduce the meaning that lies behind the
client’s words and feelings. This procedure of
deducing what the client actually means and
telling it to him at the proper time is called
interpretation.

Interpretations are not offered to provide

solutions, but rather to clear the path of the associations and to provide new ways for
the development of understanding. The therapist acts like a translator, an interpreter.

Interpretation is hardly ever a single and final pronouncement by the therapist.

Interpretations should be viewed as being tentative and intermediary. They take place in
a series of incomplete interpretations. Further associations will have to either confirm,
reject or modify these tentative interpretations.

Proper timing of the interpretations is very important. The golden rule is that no
interpretation is given until the client is close upon it himself. Interpretations may not be
given too early. Premature interpretations are either unacceptable to the client and will
provoke greater resistances on his part, or may offer some temporary relief that will cause
him to stop sharing (which may affect the process)

Interpretations may not be given too late because interpretation facilitates further
therapy. The longer the client is exposed to material which puzzles him, which seems
strange and appears to him as a foreign body, the longer the analysis will be retarded
and the appearance of new unconscious material blocked.

Interpretation is the basic tool of the therapist. All steps in the analytic therapy lead to
interpretation. The therapist is in a position to offer interpretations both because of his
great experience and because he occupies the position of detached on-looker. In
addition, he has an understanding of the difficult language of symbols, some of which
have individual meanings and some of which have universal significance.

Terminal stage of therapy

The analysis cannot be considered complete until the transference situation has been
resolved. The terminal phase of treatment, therefore, consists in the breaking of the
transference and the establishing of a normal therapist client relationship. Clients are ready
to terminate their sessions when they and their therapist mutually agree that they
have resolved the symptoms and core conflicts.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
10
 As the transference is dissolved, the client may begin to show concern over the danger
of separation and may react with new symptoms, fantasies, and resistances that must
briefly be worked through.

The progress of the analysis is determined primarily by the degree of successful analysis of
the instinctual urges and of the ego.

Other indicators for approaching the terminal phase of analysis are: clearing up of
childhood memories that have been used as resistances for important libidinous drive, the
lack of new material, evidence of an altered attitude toward life, marked changes in the
client’s social relations, plans for the future, and lessened dependence on the analyst.

INDICATIONS AND CONTRA-INDICATIONS FOR PSYCHOANALYTIC THERAPY

There are certain factors that need to be considered when conducting psychoanalytic
therapy.

1. One of the aims of psychoanalysis is to strengthen the ego by confronting and

resolving deep-seated conflicts. Hence, psychoanalysis works best for clients who are high-
functioning (eg. Intelligent, educated and reasonable individuals who are anxious to get
well).

2. Motivation should also be considered. Psychoanalysis is a lengthy, intense

process. Hence, it will require strong motivation and this must be sustained.

3. Financial considerations must be made. Therapy can be expensive, and often times,
the client is charged per session. As we have mentioned, psychoanalysis can involve
numerous sessions. That’s why financial considerations cannot be ignored.

4. Psychoanalysis is not for emergency procedures, and is not for those individuals with
acute and dangerous symptoms that require immediate action. Other forms of therapy
might be more useful in situations like this.

5. Careful evaluation of the therapist must be done to find out how far the client
can afford to have his conflicts “written out”. The client’s ego may be too weak or his life
situations may be very difficult that an analysis may make the client feel unhappier and
miserable than his neurosis.

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
11
 ELABORATE

MODIFIED PSYCHOANALYTIC THERAPIES

Over the years, modifications in traditional psychoanalysis has taken place. While the basic
system and tenets of psychoanalysis were preserved, modifications were introduced.

Alternate systems of analytic therapy

We have the neo-Freudian systems:

1. Individual Psychotherapy by Alfred Adler
2. The analytical framework of Carl Jung
3. The Will therapy of Otto Rank.

There are also neo-Freudian systems based on the cultural emphasis:

1. Holistic approach by Karen Horney
2. Interpersonal relation school of H.S Sullivan
3. Cultural approach of Erich Fromm

Other modifications and applications of psychoanalysis were also introduced. These include:
1. Brief psychodynamic therapy (BFT) which aims to shorten the duration.
2. Analytic group therapy
3. Analytic play therapy

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
12
 REFERENCES:
Corey, G. (2017). Theory and Practice of Counseling and Psychotherapy (10th edition).
Cengage Learning.
Trull, T. & Prinstein, M. (2013). Clinical Psychology (8th edition). Belmont, CA: Cengage
Learning.
Saint Louis University. Clinical Psychology Manual (Psych 25).
Wetherick, F.K. (2018). Advanced Counseling and Psychotherapy [Class Lecture].
Psychology, Saint Louis University, Baguio City.

Images:
All images were obtained from various sources, but are under Creative common license.

✔ Image 1 (“Session with a therapist”)

Link: https://commons.wikimedia.org/wiki/File:A_session_with_a_psychotherapist_(751707089).jpg

✔ Image 2 (“Woman talking”)

Link: https://blog.inkforall.com/difficult-words

✔ Image 3 (“Angry boy”)

Link: https://creazilla.com/nodes/37316-seth-man-is-angry-clipart

✔ Image 4 (“Dreaming”)
Link: https://pixabay.com/illustrations/sleep-bed-dream-thought-bubble-5655423/

✔ Image 5 (“Transference”)
Link: https://www.psychiatrictimes.com/view/critical-moment-psychiatry-need-
meaningful- psychotherapy-training-psychiatry

✔ Image 6 (“Puzzle piece”)

Link:https://www.pikist.com/free-photo-staxt

Property of and for the exclusive use of SLU. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of SLU, is strictly prohibited.
13