PSYCHOANALYSIS

Psychoanalysis, of course, very clearly originated with Sigmund Freud, although Freud gave credit to his medical
colleague, Josef Breuer, in connection with the first published appearance of the word "psychoanalysis" in 1896:
Freud spoke of a "new method of psycho-analysis, Josef Breuer's exploratory procedure" that he was now
employing to trace hysterical symptoms back to their origins. Freud chose the word "analysis" to suggest an
analogy to work done by chemists, who isolate fundamental substances, that is, chemical elements, in their
laboratories. Freud saw his work with patients as "analyzing," in that he separated out and isolated a patient's
mental processes into their elementary constituents. To Freud, a patient's symptoms were "highly complicated
mental formations" that required analysis. What has been confusing is that Freud used the words "psychoanalysis"
and "psychotherapy" interchangeably for many years, and it was only considerably later that he and others sought
to distinguish psychoanalysis from other psychotherapies.

Sigmund Freud himself provided the most complete, and now most classical definition for his invention,
psychoanalysis: "Psycho-analysis is the name (1) of a procedure for investigating mental processes which
are almost inaccessible in any other way, (2) of a method (based upon that investigation) for the treatment
of neurotic disorders and (3) of a collection of psychological information obtained along those lines, which
is gradually being accumulated into a new scientific discipline (1923a, 1922).

As defined, psychoanalysis traditionally has three distinct meanings.

1. Freud, who was trained as a physician and did basic neurological research for years, very clearly thought of
psychoanalysis as a branch of science. His laboratory was his consulting room, and his theories came directly from
his observations of his patients. So its first meaning is that it is a method of investigating the mind.

2. It is a specific treatment method designed initially to treat neuroses, such as hysteria and obsessive-compulsive
symptoms, but later used for many other disorders.

3. It is also a specific body of information, that is, a theory that explains both normal and abnormal human behavior

As such, it is a treatment that aims at a comprehensive exploration and understanding of unconscious conflicts,
character and personality development. The aim of therapy is to alter the interaction of conscious and
unconscious processes in the direction of better integration or integrity leading to improved adaptation,
maturity and health. Sigmund Freud established psychoanalysis as a combination of theory, mode of
investigation and technique of treatment. He provided a developmental approach to theory, described unconscious
defensive mechanism, and recognized transference and resistance. He emphasized the importance of psychic
trauma in his early theory and later added theories of repressed wishes and fears and their elaborations into
unconscious but active fantasies.
 Classical Psychoanalytical Theories & Therapy of Sigmund Freud

1. Topographic theory

Topographic theory was named and first described by Freud in The Interpretation of Dreams (1900). The theory
hypothesized that the mental apparatus can be divided into the systems Conscious, Pre-conscious and
Unconscious. These systems are not anatomical structures of the brain but, rather, mental processes. Although
Freud retained this theory throughout his life he largely replaced it with the Structural theory. The Topographic
theory remains as one of the meta-psychological points of view for describing how the mind functions in classical
psychoanalytic theory.

2. Structural theory

Structural theory divides the psyche into the id, the ego, and the super-ego. The id is present at birth as the
repository of basic instincts, which Freud called "Triebe" ("drives"): unorganized and unconscious, it operates
merely on the 'pleasure principle', without realism or foresight. The ego develops slowly and gradually, being
concerned with mediating between the urgings of the id and the realities of the external world; it thus operates on
the 'reality principle'. The super-ego is held to be the part of the ego in which self-observation, self-criticism and
other reflective and judgmental faculties develop. The ego and the super-ego are both partly conscious and
unconscious.

3. Anxiety

In Freud's view, the human is driven towards tension reduction, in order to reduce feelings of anxiety. Anxiety is an
aversive inner state that people seek to avoid or escape. Freud specified three major types of anxiety:

 Reality Anxiety: the most basic form, rooted in reality. Fear of a dog bite, fear impending accident. arising from an
(Ego Based removing oneself from Anxiety). Most Common Tension Reduction Method is the harmful situation.

 Neurotic Anxiety: Anxiety which arises from an unconscious fear that the libidinal impulses of the id will take
control at an inconvenient time. This type of anxiety is driven by fear of punishment that will result from
expressing the id’s desires without proper sublimation.
 Moral Anxiety: Anxiety that results from fear of violating moral or societal codes, moral appears as guilt or shame.
In this conception of Anxiety, we can see why Freud concentrated on strengthening the Ego through
psychoanalysis.

4. Defense Mechanisms

The ego balances the id, the superego and reality in order to maintain a healthy state or consciousness. It thus
reacts to protect the individual from any stressors and anxiety by distorting reality. This prevents threatening
unconscious thoughts and material from entering the consciousness. The different types of defense mechanisms
are: formation, Repression, reaction- reaction- denial, projection, displacement, sublimation, regression, and
rationalization.

5. Id psychology

After trauma psychology (which emphasize the role of repression as a defense against the repetition of
emotionally distressing traumatic memories), Freud began to work on repressed wishes and then on how
personality is formed. He suggested that the bases of personality were determined by the action of two basic
drives or instincts – libido and aggression. From biological determinants, these drives evolved into structures of
learned knowledge during infancy, childhood, and adolescence. Social experiences in interactions with significant
others affected the direction and linkages of such drives. Each individual was a complex result of nature and
nurture. This was called Id Psychology.

In addition, Freud described the evolution of character to put Psychology in a developmental sequence. He said
that the libidinal drives proceed in step-wise fashion to invest the oral, anal, and genital zones of evolving
sensation, interpersonal communication and eroticism, this is the psychosexual theory of development within Id
Psychology.

6. Stages of Psychosexual Development

Sigmund Freud (1856-1939) is probably the most well known development of theorist when it comes to the
personality. Freud's Stages of Psychosexual Development are, like other stage theories, completed in a
predetermined sequence and can result in either successful completion or a healthy personality or can result in
failure, leading to an unhealthy personality. This probably theory is the best known as well as the most
controversial, as Freud believed that we develop through stages based upon a particular erogenous zone. he
different progression, stages, listed in order of are: Oral, Anal, Phallic (Oedipus complex), Latency, Genital. The
Genital stage is achieved if a person has met all of his or her needs throughout the other stages with enough
available sexual energy. During each stage, an unsuccessful completion means that a child becomes fixated on that
particular erogenous zone and either over-or under-indulges once he or she becomes an adult.

Thus, psychoanalysts use different perspectives which include the topographic, the structural, the historical, the
psychodynamic and adaptational in trying to convey to their patients the belief that these perspectives will help
them practice effective introspection during psychoanalysis and afterward on their own.
Basic assumptions

1. Intrapsychic conflict is an all-pervasive aspect of human experience. The mind is organized to avoid unpleasure
arising out of conflict and to maximize the subjective 2. sense of safety.

3. Defensive strategies are adopted to manipulate ideas and experience in order to minimize unpleasures.
Psychological disturbance arises developmentally; an adaptation that was rational and reasonable

4. at an earlier developmental phase leaves residues that cause maladjustment in adulthood.

5. Social experience is organized into relationship representations-self and others are depicted in specific
interactions charged by powerful emotional content.

6. These relationship representations inevitably re-emerge in the course of psychoanalytic treatment.

Donna Kliene and Stephen Sonnenberg suggested four basic assumptions were useful in describing contemporary
psychoanalysis. These are:

1. That the analyst is experienced by the patient as having characteristics of important people from the
patient’s past;
2. That the patient’s actions in and outside the analysis repeat patterns from the patient’s past;
3. That some mental activity of all people takes place outside of consciousness, and
4. That people have a wish to understand themselves, to know, and that what is known can lead to changes in
the way they think, feel and act.

It should be noted that psychoanalysis and psychoanalytic psychotherapy are often referred to as the talking cure.
The term emphasized that psychoanalyst help patients by talking with them and that a conversation is central to
what heals the patient. However, it fails to stress that at the core of what heals is the relationship between the
analyst and the patient, and that their conversation is the way the aspects of that relationship are formed and
expressed.

Another useful metaphor in understanding the technique of psychoanalysis and psychoanalytic psychotherapy is
that of a dramatic performance. In the treatment relationship, the patient is 3

asked to write a play about his life, and to act many of the roles in that play in his relation with the analyst. For her
part, the analyst is asked to give herself over to the playwright patient and psychologically assume various roles
assigned by the patient in the course of their analytic relationship.

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Fundamental Concepts of Treatment

I. Transference: Transference is the displacement of feelings originally experienced toward significant

people in one's childhood (usually parents) onto the person of the therapist. As a manifestation of
reawakened erotic wishes derived from the oedipal period, the paradigmatic neurotic form of transference
occurs when the patient falls in love with the analyst. Transference is unequivocally the heart of
 psychoanalysis, and the analysis of transference is also what distinguishes psychoanalysis from all other
forms of psychotherapy. Intensive analysis of transference is the modus operandi that technically
distinguishes psychoanalysis from all other forms of psychotherapy. It has been conceptualized in various
related ways:

1. Transference as a Therapeutic Relationship:

The typical transference relationship is one in which the patient directs toward the analyst an unusual degree of
attachment and affection that is not a realistic response to the relationship between them but can only be traced to
wishful unconscious fantasies. Those fantasies are repeated in analysis as unresolved childhood attitudes and
affects that are anachronistic and inappropriate, in part because repressed material necessarily contains infantile
strivings and in part because the analyst promotes their appearance through special methods and analytic rules
that intensify reactivation. Although there is genuine (real) care and rapport that allows analytic Work to ensue,
transference as a unique unreal interpersonal bond is a function both of the inherent nature of neuroses and of the
design of the analytic situation (which facilitates regression and takes place in a state of abstinence-or lack of
gratification and leads to a substitute neurosis, the "transference neurosis").

A. The peculiarity of the transference relationship to the analyst lies in its excess in both character and degree
over what is rational and justifiable.
B. Its major manifestation may include over-endowment of the analyst as an idealized image, often including
over-estimation of the analyst’s qualities, adoption of similar interests and intense jealousy of other persons in
the analyst’s life.
C. The transference relationship is characterized as being an artificial and assymetrical bond for it is based on
projection and fantasy on the part of the patient while the analyst is characterized by neutrality and
abstinence.
D. Transference responses are characterized by the following characteristics:
a. Inappropriateness (which refers to the largely irrational character of the transference response)
b. Ambivalence (which applies to the contradictions and shifts in affect that occurs toward the
therapist);
c. Intensity (which applies to the unusual strength of emotionality);
d. Tenacity (which reflects the resilience with which such feelings tend to persist despite the analyst’s
actual behaviour), and
e. Capriciousness (which describes the erratic, and sometimes trivial events that evoke the responses).
E. As transference distortions develop, their manifestations can be either positive or negative, paralleling the
ambivalence that underlies all feelings that are in part unconscious.
a. Positive transference refers to the expression of good feelings toward the analyst, of love and its many
variations, manifested in interest, trust, admiration, respect, sympathy etc. that can predominate as the
motive force behind the wish to enageg and receive the analyst’s approval. He overvalues and endows
the analyst with some of the same magical powers attributed during infancy to the patient’s parents.
b. Negative transference, on the other hand, refers to equally intense bad feelings toward the analyst –
including hate, anger, hostility, mistrust, and rebelliousness – in which the patient undervalues the
analyst in ways that also repeat comparable feeling toward parent or parent substitutes of the past.
c. Some analysts have considered positive transference to be libidinal based on sexual drives whereas
negative transference is regarded predominantly as a function of the unresolved aggressive
strivings. It should be noted that for the most part, however, it is negative transference that becomes
most problematic and requires analysis if treatment is to proceed
F. Transference refers primarily to unrealistic distortions from the past, whether positive or negative for it
does not pertain to reactions resulting from reality factors.
 G. Transference responses are increasingly recognized as having objective as well as subjective components,
relating to significant figures of the past and to real responses of the analyst: “new editions” of the old conflicts
are exact replicas that are total projections whereas “revised editions” attach themselves to actual
characteristics of the therapist.

2. Transference as Substitute Pathology

Transference Neurosis: The most vivid expression of transference is the formation of a transference neurosis, a
substitute pathology that reiterates the fundamental pathology, in which the patient psychologically regresses to
the earliest stages of development and returns to the source of the problem in the past in order to transcend it.
Narcissistic Transference: Kohut observed that patients with narcissistic personality disorders reactivate the
specific mirroring and idealizing needs to which significant figures (self-objects) of early infancy failed to respond,
and thus they do not develop typical transference neuroses. Instead of incestuously cathected parental figures, the
central manifestations involve ways in which the patient deals with unfulfilled narcissistic needs.

3. Transference as a General Phenomenon

Beyond the boundaries of the analytic situation, in which transference feelings are particularly intense,
transference may also refer to the ubiquitous (and usually less exaggerated) tendency to displace the emotions and
forgotten memories of one's past, particularly from the earliest, most affect-laden years of life. Manifestations of
the transference-resistance can appear not only in psychoanalysis, but also in other treatment situations.

Analysts are trained to both experience and observe the drama the patient constructs in words in the analytic
consulting room. The analyst imagines herself in the world the patient creates, places herself in her imagination in
the roles the patient describes for those with whom he interacts, and recognizes how, in subtle ways, similar
patterns are created by the patient in the interactions with the analyst/ therapist. The products of those reflection
by the analyst are the various ideas the analyst conveys to the patient.

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II. Resistance:

Resistance refers to any opposition to exposing the unconscious. Resistance is defined as the forces or defensive
operations of the mental apparatus that work against the recovery of memories and that obstruct the progress of
analysis by opposing the analytic procedure, the analyst and the patient’s reasonable ego. Comparable to
transference, analyzing or managing resistances is also central to analytic work, and functions in counterpoint to
transference in two ways:

1. As resistance to the transference, which means that the patient fights against the development of a transference
and thus prevents the analyst from being able to tap the source of intra-psychic conflict;
2. As transference resistance, which means that the transference itself is used as a resistance by stubbornly
adhering to irrational transference manifestations instead of utilizing the transference as a path to earlier
experiences and memories.

Resistance can be conscious or unconscious, and can be produced by the ego, the id, or the superego.
 Conscious resistance refers to the deliberate withholding of information from the analyst, or the like.
 Unconscious resistance, however, refers to a much more significant and resilient phenomenon that arises
 as a defense against emotionality and memory.

The clinical signs and manifestations of resistance are manifold

 Any persistent, stereotypes or inappropriate interruption of the treatment process may be a clue to
resistance.
 Common examples include the silent patient, who impedes the progress by failure to verbally, and at the
other end of the spectrum, the compulsive talker, who disobeys the fundamental rule to say whatever
comes to mind, but whose verbal productions are unconscious barriers to insight.
 Specific variations of resistant behaviour may be undue focus on the past or incessant inclusion of external
events in order to avoid painful or emotionally-laden topics. Typical forms of resistance also include
lateness, missed hours, and delaying to pay one’s bill.

As such, managing resistances means that the defensive maneuvers of the patient are to be addressed before the
material that is tended off can be approached. The analyst must discover how the patient resists, what is being
resisted and why.
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III. Counter-transference

Counter-transference refers to transference in the reverse direction – from analyst to patient. It generally refers to
unconscious emotional needs, wishes, or conflicts of the analyst evoked by the patient, which are brought into the
analytic situation and thus influence the analyst’s objective judgement and reason. The psychoanalyst being
participant observer enables to have a fuller appreciation of the drama of the patient’s life by dint of counter-
transference. The analyst does not act on the counter-transference but rather uses her awareness of these feelings
as further information to grasp an understanding of the patient’s world. The term "counter-transference" was
coined by Freud in 1910.

Counter-transference manifests itself in many ways:

 it is commonly acute, temporary, superficial, and easily recognized and managed; but it can also be chronic,
permanent, deeply rooted, largely unconscious and out of the analyst’s control.
 Acute countertransference may occur in response to very specific content that arises or in identification
with some concrete aspect of the patient’s personality.
 Chronic countertransference involves more general and ingrained patterns of behavior, orten pathological,
that pervade the analysis in a way that is not therapeutic and to which the analyst
 Classic counter-transference may manifest themselves in special consideration for an attractive patient,
like eagerly making an unavoidable hour of an uninteresting patient.

The following are considered common warnings of counter-transference:

 Experiencing uneasy feelings during or after sessions with certain patients;

 Persistently feeling drowsy or actually falling asleep;
 Altering sessions or showing carelessness regarding scheduling (eg. extending hours or forgetting
 about them);
 Making special financial arrangements wishing to help the patient outside the session;
 Dreaming about one’s patients or being preoccupied with them in one’s leisure time;
 Using the patient as an example to impress a colleague or having the urge to lecture or write about a
particular patient;
 Reacting strongly to what the patient thinks of the analyst;
 Not wanting the patient to terminate or wanting the patient to terminate;
 Finding oneself unable to explore certain material or to understand what is going on with the patient;
and
 Evincing sudden or excessive feelings (eg. anxiety, depression or boredom).

Counter-transference is presumed to relate primarily to unresolved and irrational response; yet it may also refer to
an analyst’s relatively reasonable reactions to a patient’s behaviour, as when feelings aroused by a seductive
patient, paternal to a deprived patient, frightened by an aggressive patient, burdened by a demanding
patient, or jealous of a successful patient. As such, counter-transference feelings are an inevitable part of any
treatment. However, when these feelings are not simply situation-specific, and evolve strong reactions that belong
to former events or persona in the analyst’s life, they can become problematic because the analyst is in danger of
bringing these unconscious feelings into the analysis in the form of unnecessary, if not actually non-therapeutic
behaviours.

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IV. Therapeutic Alliance: The therapeutic (or working) alliance is the task-oriented collaboration between
therapist and patient in which the therapist's aims are to form an alliance with the conscious adult ego of
the patient and to encourage the patient to be a scientific partner in the exploration of his or her problems.

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V. Real Relationship: The real relationship is the realistic (reality-oriented and undistorted) and genuine
(authentic and tue) aspect of the therapeutic relationship. It is contrasted with the transference, which is
genuine but unrealistic, and the working alliance, which is realistic but not genuine (i.e., an artifact of the
analytic situation).

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VI. Interpretive Process:

Interpretation involves the special skill (or art) by which the analyst deciphers the latent meanings of the
patient's verbalizations and translates them in a way that can be comprehended and accepted. It includes
hidden historical connections between present and previous behaviors, between feelings toward the analyst
and those meant for significant others, between instinctual impulses and defenses built against them, and,
ultimately, between conscious thoughts and unconscious wishes traced to their infantile roots. The major
techniques of psychodynamic treatments are fostering expression, suggestion, clarification, interpretation
and repetition in order to facilitate working through.

a. Fostering Expression: Confrontation

Fostering expression includes helping the patient to assume most of the responsibility for bringing up topics of
importance. He/ she is encouraged to broaden the topics of discussion beyond the scope of original complaints.
The fundamental rule is to try to say everything that comes to mind or is felt in the body. It is also to be noted that
the analyst often points out, in a kind way, that expectations or ideas of the patient are quite different from what
the patient realized them to be. Thus, the analyst must be prepared to vigorously confront the patient, when
necessary.

b. Suggestion: The therapist may suggest that the patient attend to certain topics, follow certain principles of
disclosure, or try out certain alternative modes of perceiving, thinking, feelings or acting. The choice about whether
or not to follow such suggestions is left to the patient. From directions are seldom, if ever, given and any type of
manipulative and covert suggestion is avoided.

c. Clarification: This includes techniques of questioning or repeating what the patient has told the therapist.
Even when the therapist repeats exactly a bit of dialogue spoken by the patient, it sounds different when the
patient hears the remark. When the therapist reorganizes information reported by the patient, it is usually to
convey cause-and-effect sequences and to show the patient the meaningful relatedness of sequences that have
seemed to the patient as unrelated.

d. Interpretation: Interpretations are often seen by analysts as the crown jewel of the methods available to help
patients think more effectively about themselves. Interpretations involve telling patients in a convincing way that
there is an unconscious process at work in their thinking and, in a complete interpretation, explaining exactly why
and how that unconscious process works. It is the addition of the developmental explanation of the feelings, wishes
and hopes that makes an interpretation a linking the past with the present in a convincing manner.

 Transference-interpretations explain to the patient the meaning of distortions in the relationship with the
therapist.
 Dynamic interpretations explain to the patient that forces involved in a conflictual constellation while
dream interpretations explain to the patient the concerns and symbolic that may lie behind the formation
of dream images.

It is to be noted that interpretation is not enough to induce psychic change. In fact, the change process beyond
interpretation is called working through.

Repetition and Working Through:

The working-through process involves repeated examination of the same topic. If the treatment is progressing,
each repetition is perhaps a bit different and contributes to the overall decrease in repression and increase in
understanding. Some new aspect of conflict may be identified, and new linkages between topics are established.
Realization of developmental antecedents of current conflicts helps the task of differentiating current reality from
past fantasy.

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VII. Insight:

Insight has been defined as the process by which the meaning, significance, pattern, or use of an experience
becomes clear or as the understanding that results from that process. Theoretically, it has been portrayed as
occurring in four successive stages, which can be applied to the psychoanalytic process as follows:

(1) Preparation, characterized by frustration, anxiety, feelings of ineptness, and despair, often accompanied by
trial-and-error activity and falling into habitual patterns (repetition compulsion);
 (2) Renunciation, in which one desires to escape from the problem or is unmotivated to make insightful efforts
(resistance, negative transference);

(3) Inspiration or lumination, in which the problem is grasped and solutions suggest themselves (beginning of
discovery based on interpretive process); and

(4) Elaboration and Evaluation, in which the validity of the insight is checked and confirmed extemal against
reality (working through). Insight in psychoanalysis is not definitive in its role or its function. There is no proof
of a necessary relation between the truth (or falseness) of insight and therapeutic results, although that
clinically obviated by the finding may be role of mutual belief as a nonspecific healing agent

Four technical concepts of psychoanalysis and psychoanalytic psychotherapy are important to therapeutic
process - free association, the metaphors in the patient’s words, freely hovering attention as a mode of
analytic listening and freely hovering role responsiveness as a mode of establishing the counter-transference
during analytic listening.

a. Free Association: Freud viewed therapy as making the unconscious conscious. He developed the important
technique of free association where the patient is encouraged not to suppress or edit what comes to mind and not
to always focus on a specific topic but to verbalize one’s unconscious feelings in a stream of conscious
representations. He is encouraged to set aside restrictions on thoughts and reporting that occur because of feelings
of embarrassment, shame or fear that these emotions bring. The play of different defense mechanisms can be
understood thoroughly by the therapist by dint of the free association method. The patient is instructed to say
anything that comes to his mind, to suspend the usual effort to think clearly and make sense so that the analyst is
able to hint at the unconscious layer of thinking of the patient.

b. Focus on Metaphor: The analyst listens to the patient, may take the help of dream analysis in search for
symbols and for metaphor to educate the patient and facilitate an understanding of the meaning of the thoughts
and the way of thinking and an appreciation of all the mental activity which is outside conscious awareness.

c. Freely hovering attention as a mode of analytic listening: As the analyst/ therapist listens to the patient’s free
associations, he/ she listens for the patient’s unconscious mental activity. In this listening, the analyst is sensitive
to the symbolic communications of the patients. The analyst listen in a creative, imaginative frame of mind, in
which layering of meaning and symbols become vivid experiences for the analyst.

d. Freely hovering role responsiveness: The analyst, practicing abstinence, neutrality and anonymity, and using a
freely hovering role responsiveness that has thus identified an unconscious meaning in the request, will be able to
convey to the patient the particular meaning of the patient’s associations and actions within the analytic relation,
making him willing to explore his desires to further gain weight

e. Analyst as "Mirror: A principal recommendation that the analyst be impenetrable to the patient and, like a
mirror, reflect only what is shown. Analysts are advised to be neutral blank screens and not to bring their
personalities into treatment. That means they are not to bring their values or attitudes into the discussion or to
share personal reactions or mutual conflicts with their patients, even though they may sometimes be tempted to do
so.

Complications: It has been observed in exploratory psychoanalysis that some patients have an initial period of
effective work and then have deterioration in their condition. This has been called a negative therapeutic
reaction. It is important in such instances for the therapist to be self-observant for feelings of hopelessness, guilt
and anger, and to aim instead for understanding with the patient why the condition has got worse. In other areas,
early interpretation of negative transferences and/ or very early emphasis on signs of the therapist being helpful
in a therapeutic alliance may be needed to prevent from dropping out prematurely in the midst of a negative
transference reaction.

The method of psychoanalysis has got two components:

1. The setting, : The setting is an intensive psychotherapeutic setting where the patient is seen 4/5 times a week to
enable the conscious experience and analysis of unconscious emotional conflicts. Psychoanalysis takes place in a
professional setting, where the patient is offered temporary sanctuary in which to ease psychic pain and reveal
intimate thoughts to an accepting expert. The psychoanalytic environment is designed to promote relaxation and
regression. The setting is usually spartan and sensorially neutral, and external stimuli are minimized.

Use of the Couch: The traditional setting is a formalized part of the psychoanalytic heritage, still modeled on the
physical arrangement of Freud's medical office at Bergasse 19 in Vienna. The analyst's couch is the most enduring
structural requirement. The couch allows the patient to lie down within view of the analyst, who remains seated in
a chair outside of the patient's field of vision. The couch has several clinical advantages that are both real and
symbolic:

- (1) The reclining position is relaxing as it is associated with sleep and eases conscious control of thoughts

- (2) It minimizes the intrusive influence of the analyst, thus curbing unnccessary cues

- (3) It permits the analyst to make observations of the patient without interruption;

-(4) It holds symbolic value for both parties, a tangible reminder of the Freudian legacy that g'ves credibility to the
analyst's professional identity, allegiance, and expertise.

2. The technique: The method provides privacy and confidentiality, with the main technique being free
association.

Goals

 Psychoanalysis aims at the gradual removal of amnesias rooted in assumption early childhood, based on
the that when all gaps in memory have been filled, the morbid condition will cease because the patient no
longer needs to repeat, or remain fixated to, the wishes past. Giving up infantile and not having to
recapitulate early inappropriate behaviors the patient should be better able to relinquish former regressive
patterns and to develop new, more adaptive ones, particularly as he or she leans the reasons for his or her
behavior.
 A related goal of psychoanalysis is for the patient to achieve some measure of self-understanding, or
insight and have a relief of symptoms.
 Psychoanalytic goals aim at radical reorganization of old affects and the entrenched developmental
patterns based on earlier defenses built up against them.
 In practice, the goals of psychoanalysis for manifestations of neuroses. Such any patient naturally vary, as
 do the many goals may change at any time during the course of especially given that many analysis, years of
treatment may be involved.

The Ground Rules and Context of Psychoanalytic Treatment:

The goal of therapy is to improve the future for the patient. Early party to the treatment has tasks in relation to
this goal. The patient is asked to speak truthfully and completely about memories, fantasies, associations, images,
dreams, bodily feelings, wishes and fears that are usually not told to others. The therapist and the patient together
observe what it feels like to do this, how it is done, what is communicated, and what the process does to their
relationship. The therapist puts this understanding into words in the form of interpretations, which are intended to
connect the patient’s present feelings with his/ her past, giving a broader picture about meanings, including those
that have never before been verbalized. In psychoanalysis, the two people explore private themes, personal
dilemmas, conflictual memories and unsettling feelings of one of them.

The analyst offers a relationship in which there is respect for the personal attitudes and feelings of the patient.
The therapist also displays more equidistance, abstinence and neutrality than one would expect of other
relationships as with friends, teachers, parents etc.

1. Equidistance means that the therapist is “there” not just for the adult, poised, competent self-schema of the patient,
and the states of mind organized by that set of concepts and images, but also “there” for the patient’s ideals and
values and also “there” for the child-like self-schemas and immature passions of the patient. The therapist does not
side with any sector or any variety of self-schematization of the patient, but remains available as a container for
all facets of conflict.

2. The term abstinence refers to the fact that the analyst avoids gratifying the patient’s wishes, whatever they might
be. Instead, the analyst’s task is to understand and to convey the patterns of inter-personal rating that emerge and
reflect the past experience of the patient.

3. Neutrality is a related concept, which means that the therapist does not react emotionally as he/ she would in a
social situation according to his/ her own wishes, ideals and moral standards. It is not coldness or indifference:
warmth, compassion, concern, sympathy, empathy, and understanding are not deflections from neutrality but
absolute requirements for the therapist if the treatment is to achieve it full goal. The analyst maintains neutrality;
does not express personal preferences to the patient and provides limited information about his/ her own life.
4. Patient Requisites : The most important patient requisites for psychoanalysis are the following:
a. High motivation: The patient needs a strong motivation to persevere in light of the rigors of intense and
lengthy treatment.
b. Ability to form a relationship: The capacity to form and maintain, as well as to detach from, a trusting object
relationship is essential. The patient also has to withstand a frustrating and regressive transference
without de-compensating or becoming excessively attached.
c. Psychological-mindedness and capacity for insight: As an introspective process psychoanalysis requires
curiosity about oneself and the capacity for self-scrutiny
d. Ego strength: Ego strength is the integrative capacity to oscillate appropriately between two antithetical
types of ego functioning: On one hand, the patient must be able to be dependent and passive. On the other
hand, the patient has to be able accept analytic rules.
e. In addition, Freud felt that people "near or above the age of 50" were too old and inflexible for
psychoanalytic treatment. Few analysts today would accept that limitation.

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The treatment can be divided into three overlapping phases as follows:

1. Induction Phase: the first phase, or the initiation of treatment, involves "getting to know the patient” learning
about the characterological stvle, defensive maneuvers, and the danger situations that rule the patient's behaviors.
It is also the period in which rapport is established and the therapeutic Solidified. The rules of therapy are
explained (free association, reporting of dreams, patient's possibilities, therapist's responsibilities). Initial
resistances to the treatment process may be noted by therapist and stored for future reference or may be explored
immediately (this must be done first if the nature of the resistances threaten to end the treatment). Early
transferential responses by the patient are Likewise noted and stored for future use in the treatment when a better
understanding of the patient's past experiences will shed light on the present transferential responses..

2. Middle Phase: The middle phase of treatment is when the emotional history starts to progressively unfold. The
transference intensifies, consolidates and focuses intensely on the psychoanalyst, leading to the establishment of
transference neurosis. Symptoms express defenses. As defenses are analyzed and unraveled, as their functions
become more known and more conscious, the underlying, conflicted emotional experiences they protest against
emerge more clearly. The analysis of defenses and of underlying conflicts allows for the better resolution of
unhappy, symptom-generating and maladaptive attitudes. If the working alliance is solidified, the patient will have
the ability to experience these real feelings and thoughts in the present, while at the same time observing the
repetitious nature of these responses from the past. Working through conflicts begins at this time in the treatment
- that is, noting the patterns of the past which are repeated in one's present life with others outside of the
therapist's office, as well as with the therapist in the office. Memories from the past are recalled and one's view of
the past, previously distorted by wishes and fears, becomes increasingly clear. This leads the patient to experience
wider choices in life, since past distortions no longer cloud present decision making.

3. Termination Phase: It is the last phase and is an intense period of treatment. During this phase,
there is an internalizing of the psychoanalytic process itself so that patients can continue
understanding their mental life on their own. Patients are able to do some free association for
themselves and to understand the central themes of their personality, dramatized in their fantasies
and dreams. They can therefore figure out their new unhappy feelings and the reality triggers causing
them and plan to meet those reality challenges in ways that will be satisfying as possible.

Resistance to termination can be seen as impediments to developmental processes. The therapist and
therapy are invested with indispensability, an illusory and anachronistic carry-over of infantile needs
and wishes into the present. The therapist fails to meet the client’s overweening need and so cannot be
relinquished. Or the therapist provides only the maternal half of the parental imago, and so cannot
point the client towards independence. Hatred and need are so stark that they cannot be brought
together into the depressive position. ‘Failure’ (in the sense of ‘good-enoughness’) is only bearable if
balanced by a sufficient bank of success.

Novick (1997, p. 145) convincingly argues that, with honourable exceptions (Balint 1968) ‘neither
Freud nor his followers paid much attention to termination as a phase of treatment’ and that ‘for
almost 75 years psychoanalysts have been unable to conceive of the idea of a terminal phase…’.

Reasons:

• Ending therapy, as with embarking on one, is a REAL EVENT, an ‘enactment’ going beyond the
bounds of transference and the imagination.

• Psychoanalysis struggles to theorize the real relationship

 • The question of termination overlaps, sometimes in confusing ways, with the issue of the aims and objectives of
analytic therapy and what a ‘good outcome’ might be.

• Psychoanalysts themselves never fully undergo the process of disengagement which awaits the average
analysand.

Setting up a therapeutic relationship is an inescapable ‘enactment’ on the part of therapist and client: an action
that is ‘real’, observable, performed rather than merely imagined, phantasised about, or desired. The latter comes
into play as the meaning of actions and their psychological reverberations become grist for exploration, but a vital
pre-condition is the alleviation of attachment insecurity. But if the reality of establishing an attachment
relationship is central, so too is its ending. For Bowlby (1973), separation was the flip-side of attachment: the very
purpose of attachment behaviours, on the part of both care-seeker and care-giver, is to mitigate loss. Crying,
proximity-seeking, responsiveness and soothing all work to ensure that an individual when vulnerable – whether
through physical immaturity, illness, or trauma – gains and maintains access to protection and succour. When
separation is irreversible – i.e. at an ending – Bowlby and his followers such as Parkes (2006) identified the now
familiar constellation of reactions and feelings: denial, angry protest, searching, despair, and recovery leading to
the establishment of new attachments.

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Application of some ideas and findings to therapy termination as a bereavement analogue:

First, a key issue in reactions to separations is not so much the physical presence, but the continuing availability
when needed of the attachment figure (Klass et al. 1996). This ‘sense of availability’ can transcend the total
separation implicit in a death and makes grieving bearable.

Attachment styles have a significant bearing on reactions to loss. There are two main patterns of
pathological mourning: denial and chronic depression of mood on the one hand; and inconsolable
preoccupation with the lost loved one on the other (Parkes 2006). These map well onto the two
principal patterns/styles of insecure attachment, deactivation of separation of protest and
hyperactivation and inconsolability (Mikulincer & Shaver 2006). In the former there is denial that the
absence of the lost one ‘matters’, while physiological and psychological explorations reveal otherwise.
In the other, there is a doomed and un-assuagable effort to recover the lost loved one.

The ‘transactional model of attachment’ (Sroufe 2005) suggests a dynamic interplay between
attachment style and current relationships that accounts for variable outcomes in loss. An ending is
‘polysemic’ (Tuckett et al. 2008). Depending on mood and perspective, the meaning of an ending can
be a death, a bereavement, a completion, a liberation, a funeral (with or without a tearfully convivial
wake) or a joyful moment of maturation and ‘leaving home’. The attachment-informed perspectives
have a number of clinical implications. First, therapists should bear in mind the client’s predominant attachment
style.

Clinical folklore holds that as the end of therapy approaches the client’s symptoms, even if alleviated during the
course of therapy, may re-appear. This is perhaps particularly likely for hyperactivating clients who may
overestimate the negative impact of ending. The therapist may be tempted into a premature proffering of
extensions or suggesting an alternative therapist or therapy (such as a group), in ways that are driven by counter-
transference-induced guilt rather than clinical need. Such post-therapy arrangements may well be appropriate, but
should not be allowed to divert therapeutic focus from first working through the ending. The client’s social context
should be taken into account when deciding on either offering time-limited therapy, or finding an appropriate
moment to conclude open-ended treatment. The therapist needs to consider the meaning of ‘availability’ and
‘continuing bonds’ as conditions for secure attachment – the latter being a key outcome goal for therapy.
Responses to ending can be theorised bringing together the Bowlbian perspective with Kleinian ideas of working
through loss (1940).

Termination as co-construction

The relational approach takes it as axiomatic that the clinician’s as well as the client’s states of mind need to be
taken into account if clinical phenomena are to be fully explored and understood. Analysis at its best involves the
direct communication of one unconscious (the patient’s) with another (the analyst’s), the role of the analyst’s
implicit character and belief system is acknowledged. Second, and flowing from this, comes the idea of the ‘analytic
third’ (Ogden 1987; Benjamin 2004 ), the unique relational structure of any given therapy, built from the differing
contributions of clinician and client, but directly derivable from neither.

Any given client will have a different therapeutic experience with different therapists, and that a given
therapist will establish very different therapeutic relationships with different clients. It should also be
noted however, in contradiction of an absolutist relational viewpoint, that ‘difficult’ clients tend to do
badly by whomsoever they are treated, and that excellent clinicians tend to make most of their clients
better (Beutler et al. 2004); in the latter case, it may be the very flexibility and capacity to accept
differing ‘analytic thirds’ that contributes to these ‘super-therapists’ success.

Therapists need to be aware of and allow for their own attachment styles if they are to offer mutative
rather than quasi-collusive treatments. Each analyst will have her or his unique ‘termination style’,
evoked to some extent by any given patient, but also manifesting his or her own attachment history
and predilections. The lineaments of an ending need to be thought about as co-constructed. The task is
not so much to get it ‘right’, as to use the ending as a powerful exemplar from which the client can
learn about the ways his unconscious shapes the way he handles, and has handled, loss and separation.
In facilitating this, the therapist must abstract her own attachment style from the therapeutic equation
in order to see the client’s for what it is.

Hence, to summarize, a method is said to be psychoanalytic if it has certain crucial elements of

treatment, namely, the analysis of resistance and defense in the making conscious of unconscious
conflicts and their compromises, use of transference as a vehicle to understanding some efforts to
reconstruct past patterns as they influence present functioning and frequent sessions so as to achieve
the goal of the progressive unfolding of personality psychology.