Randall D. Ordovich Clarkson, MD
August 12, 2022
PSYCHOANALYTIC THEORY: A BRIEF OVERVIEW
Throughout the early 20th century, Dr. Sigmund Freud and his contemporaries, including Dr. Alfred Adler and Dr. Carl G. Jung, laid down the framework of what would revolutionize the field of behavioral health through a process of “talk therapy” referred to as psychoanalysis. One of the goals of traditional psychoanalysis is to bring the patient’s pathological or otherwise destructive subconscious thought processes into conscious observation in order to allow for the development of insight. The foundational principles of psychoanalytical theory follows that our actions and motivations stem from deeply unconscious processes that we are not fully aware of. These processes, furthermore, may be rooted in negative experience stemming from one’s childhood or family and social dynamics. Thus, in order to obtain insight, one must reach deep into the patient’s history to discover the roots of their current modes of being.
As Murdock (2017) poetically explains, “The real motivations—the instincts in the unconscious—lie beneath the surface of the stormy ocean” (p. 35). These motivations may indeed run so deep that they define one’s entire existence and relationship with the world around them. In many cases, insight development would be best established by addressing the “unresolved unconscious conflicts originating in childhood” (Murdock, 2017, p. 48). Through the combined psychoanalytic mechanisms of free association, interpretation, analysis of resistance, dream analysis, and analysis of transference, the therapist may help provide the client with insight necessary to resolve their subconscious hold-ups.
Carl Jung writing in 1956 describes how physicians may feel hurried in their approach to treating patients, and how free association may serve as a respite for such sentiments, allowing the patient to self-disclose their problems at their own volition (Jung, 2012). In such pursuits, dream analysis can play a pivotal role, allowing practitioners to analyze the symbolic substance of one's sub-conscious visions. In such a process, Jung (2012) explains that Freudian free association allows for "letting the patient go on talking about his dream-images [...] to give himself away and to reveal the unconscious background of his ailment" (p. 67). Jung concludes that, "Anyone who talks long enough will inevitably betray himself by what he says and what he purposely refrains from saying" (p. 67). In this essay, let us understand the manner by which Freudian psychoanalytic methods can help to understand and address a patient's presenting symptoms.
...our actions and motivations stem from deeply unconscious processes that we are not fully aware of.
CASE STUDY
Let us consider a fictitious vignette involving Mrs. A., a 25 year old patient from Guatemala, who is fluent in both English and Spanish. Mrs. A. presents with a recent job loss, feelings of hopelessness, weight-loss of 10 pounds over 2 months and concerns of becoming homeless. She is married with a young child; however, her husband is in the military and is currently on deployment. Upon initial evaluation, Mrs. A. is tearful, states she is anxious and depressed, avoids eye contact, and has a flat affect. Having completed 1 year of college, she worked as a banker; though she was furloughed three months ago. Despite coming from an affluent family in Guatemala, she refuses to ask them for financial assistance. She has 4 siblings all of which graduated college with professional careers. Mrs. A. states that she is 'close' to her family although she has not seen them for a year. Her father is a banker and a 'heavy drinker.' Her mother works as an educator. Both her parents have been married for 27 years. Mrs. A. states that she feels alone and overwhelmed, having to raise her 1-year old daughter alone. The patient commits to 8 sessions of psychotherapy.
THERAPEUTIC GOALS AND INTERVENTION STRATEGIES
In addressing the issues for Mrs. A., the 24-year-old patient presented in the case-report, one may utilize a multitude of approaches. In Mrs. A.’s case, which involves predominantly depressive and anxiety related symptoms, she could potentially benefit from psychoanalytical or psychodynamic models. In a study by Murdock (2017), it was found that in 33% of reported cases, “the most common theoretical orientations of their therapists were psychoanalytic or psychodynamic” (p. 19). Furthermore, counseling models have been found to be as effective as drug therapy; however, according to Mudock (2017), “slightly more positive outcomes were reported by clients who engaged in both” (p. 13).
Psychoanalytic theory suggests that depression, such as the case presentation for Mrs. A., may involve “basic preoccupation with libidinal issues of interpersonal relatedness” (Blatt, 1998). Such issues may also involve avoidant defense mechanisms to, “cope with psychological conflict and stress” (Blatt, 1998). For Mrs. A., these issues stem from a variety of factors, including recent loss of employment, being the sole caretaker of her 1 year-old child, her husband’s military deployment, and a challenging relationship with her father figure. All of these issues must be explored and addressed using a variety of psychoanalytic methods.
Firstly, Mrs. A.’s anxiety and depression is stemming most directly from her recent job loss. This job loss would be considered her primary stressor. For someone who is extremely independent and self-reliant, this type of economic uncertainty will inevitably bring about a great deal of fear; particularly considering that her husband is not present to serve as moral support. Blatt (1998) states that individuals with propensities towards anxious attachment are in great need for both interpersonal contact and may be excessively dependent; though the latter does not necessarily apply to Mrs. A. On the other hand, as argued by Blatt (1998), “Compulsively self-reliant individuals are excessively autonomous and avoid close, intimate, interpersonal relationships.” These preoccupations provide the grounds for Mrs. A. to be vulnerable to depression. Additionally, Mrs. A. is likely suffering from adjustment disorder (AjD) subsequent to her involuntary job loss. This is resulting in preoccupation with her stressor and the inability to adapt.
According to a study by Lorenz et al. (2018), “Higher loneliness, higher dysfunctional disclosure, and lower self-efficacy were associated with both higher symptom severity and higher likelihood of meeting the diagnostic criteria for AjD.” With Mrs. A.’s lack of social support, she certainly fits this criteria. Therefore, the second main objective would be to explore Mrs. A.’s social circumstances. Blatt (1998) states that, “Anaclitic or dependent depression is characterized by feelings of loneliness, helplessness, and weakness; these individuals have intense and chronic fears of being abandoned and left unprotected and uncared for.” In exploring this issue, the therapist can help Mrs. A. surface her attachment issues so that she can develop better coping mechanisms and insight.
One final consideration is exploring Mrs. A.’s “close” relationship with her family. Objectively, one can point out that she does not have family support, particularly from her father who likely suffers from alcoholism. Additionally, she has not seen any of her family members in one year. Despite this, Mrs. A. states that she is “close” to her family. The therapist can help Mrs. A. discuss this and see what lays at the root of her denial and why she has been unable to seek out adequate emotional support from her family.
PROCESS OF TREATMENT
Mrs. A.’s therapeutic process will likely require multiple sessions beginning with free exploration of her thought processes. In a study by Ben-Itzhak et al. (2012), they compared the results for 12 sessions of brief psychotherapy (3 months) and intermediate psychotherapy (12 months) for the treatment of AjD and depression. Their findings were that, “After 3 months of therapy, both groups of patients showed significant improvement.” Their study also concluded that no additional improvements were observed in those who continued therapy for the full 12 months. Mrs. A. is willing to commit to 8 sessions; though, if necessary, this can be re-evaluated as she may benefit from a total number of 12 sessions over a three-month period.
In accordance with Freudian psychoanalytic theory, the analyst can begin by providing unguided time for Mrs. A. to express whatever comes to her mind. This free association will allow unconscious motivations to be brought to the surface with total honesty and without Mrs. A. attempting to make sense of these thoughts (Murdock, 2017, p. 47). During this time, Mrs. A. would be required to be lay on the couch in order to avoid eye contact with the analyst, creating an abstentious atmosphere (Murdock, 2017, p. 47). During this free association process, Mrs. A. may discuss the anxieties stemming from her recent job loss, raising an infant alone, issues with her childhood and family, and any revealing dream phenomenon.
Over time as data is gathered, the analyst can then begin the interpretation process, providing Mrs. A. with information pertaining to her freely associated thought process. It will be crucial for the analyst to begin by discussing Mrs. A.’s relationship with her alcoholic father. Her motivations for being independent may strive from her desire to maintain autonomy, breaking away from family attachments. Despite claiming that she has a “close” relationship with her family, she is in clear denial of the actual distance that she has somehow managed to maintain from her social support. In that, her depression may involve different factors that can be distinguished in this process. These insights are detailed below.
During this time, it is important for the analyst to take note of any resistances that may come up during the interpretation process. For instance, Mrs. A. may resist the notion that she is indeed distancing herself from her family as she is in denial of how “close” she is to her relatives. However, it is very common for depression to arise from a lack of social support. A study by Grav et al. (2012) found that lack of social support is directly associated with Hospital Anxiety and Depression Scale‐defined depression and in particular, “women seem to need more emotional support and men tangible support.” Other types of resistances are important to note including being late to or otherwise missing appointments or remaining silent during sessions (Murdock, 2017, p. 51). Also, Mrs. A. may express a desire to cease therapy prematurely, feeling that her symptoms are improving. This phenomenon is described as “flight into health” and is considered a form of resistance (Murdock, 2017, p. 51).
Other aspects of analysis can involve the role of transference. In Mrs. A.’s case, she may begin transferring her paternal support role onto the therapist, particularly since she is in a state of social isolation. Such a dynamic would provide a great deal of information for the analyst’s interpretation process.
SOCIAL AND CULTURAL NEEDS OF THE CLIENT
Mrs. A. is a first-generation immigrant from Guatemala. This background may indicate that she wants to strive and succeed in the United States. As a foreign-born woman, she may wish to establish herself as a hard-working independent immigrant. Her recent job loss, however, is obstructing her perceived opportunity of doing so. According to Beck (1983), individuality and autonomy involves an individual’s, “investment in preserving and increasing his [sic] independence, mobility, and personal rights; freedom of choice, action, and expression; protection of his [sic] domain, […] and attaining meaningful goals” (p. 272). Furthermore, as stated by Blatt (1998), “Highly autonomous, achievement-oriented individuals are very concerned about the possibility of personal failure and often try to maximize their control over the environment in order to reduce the probability of failure and criticism,” concluding that, “Depression can be a byproduct resulting from perceived failures and “lack of control over the environment.” The inability to attain these goals is providing great anxiety for Mrs. A. In the psychoanalytical context, the therapist can provide this interpretation to Mrs. A., which will hopefully give her insight into her motivations.
Another interpretation could include the need for Mrs. A. to establish an adequate social support system. This may involve re-establishing a close relationship with her siblings and her parents. It is very likely that her family is oblivious to the turmoil she is experiencing and disclosing her state may prompt them to become more involved in her life. As she is experiencing challenges raising her child while balancing other aspects of her life, her family may help provide either direct care for her baby or provide resources to help her with adequate daycare options. Secondly, the therapist could encourage Mrs. A. to reach out to local Guatemalan groups or organizations. This could provide additional support systems as well as allow Mrs. A. to remain in touch with her cultural roots.
VALUABLE INSIGHTS
The ultimate goal of psychoanalysis for Mrs. A. would be the development of insight into her condition. This may not fully cure her of the underlying conditions resulting in her symptomatology, but would provide her with a framework to circumvent her automatic negative thoughts stemming from her subconscious modes of thinking. Murdock (2017) describes this result as still having the “same tendencies” of negative emotive experience coupled with adequate insight of such in order to “operate based on ego rather than id or superego processes” (p. 55).
According to Blatt (1998), it is important to, “differentiate between a depression focused primarily on interpersonal issues such as dependency, helplessness, and feelings of loss and abandonment and a depression derived from a harsh, punitive superego—a depression focused primarily on self-criticism, concerns about self-worth, and feelings of failure and guilt.” It is possible that there are two mechanisms at play for Mrs. A. First, she is in a state of helplessness, being previously independent but now struggling with economic insecurity. Secondly, she is dealing with issues of self-worth, being unable to adequately achieve her desired state of independence. Both of these factors are certainly contributing to her state of crisis and potential AjD.
In addition to the aforementioned factors, Mrs. A. is likely struggling with estrangement from her family members. The analyst can help provide insights as to why this is the case allowing Mrs. A.’s unconscious motives to be brought into conscious thought. This may help her overcome any potential feelings of insignificance, insecurity, or hesitance to reach out to family for needed social support.
IMPLEMENTATION OF THE FREUDIAN PROCESS IN COUNSELING
The Hippocratic Oath of primum non nocere,” translated as “First do no harm” and classically written as “I will keep them from harm and injustice” is the best fundamental approach for any practitioner in healthcare (Hughes, 2007; Tyson, 2001). As Hughes (2007) argues, “Prevention of injury and illness is another significant aspect of medical practice.” Throughout the psychoanalytic process, it is critical that the therapist avoid causing any harm to the client, adhering to ethical guidelines of the field. Silverman (2017), for instance, “cautions against losing sight of analysts’ need to distance themselves enough from their own subjectivity to value and respect their patients’ need to lead the way.”
During the interpretation process, the analyst runs the risk of imposing their personal values onto their client. This value-imposition should be avoided. Instead, the therapist needs to do their best to operate within the moral framework of the patient, encouraging the patient to achieve insight within their worldview. If any resistance to therapy should arise, the therapist can tactfully explore the root of these issues. In that, Mrs. A. may maintain autonomy and arrive at insights at her own volition.
CONCLUSION
Mrs. A. is experiencing a life-changing situation that many people suffer through: economic insecurity with a lack of social support. Because of this, she is likely suffering through AjD which is resulting in tremendous anxiety, depression, and a sense of hopelessness. Throughout the psychoanalytic process, these problems can be addressed by exploring her familial relationship, her anxieties surrounding being the sole-caregiver for a child, and the sense of failure stemming from her recent job loss. Psychoanalysis can prove to be very beneficial in helping Mrs. A. regain control over her unconscious thought processes and not succumb to her perceived sense of inadequacy. At this time, she likely feels that there is no recovering from her job loss. This does not have to be permanent for she can still obtain gainful employment. Furthermore, her lack of social support is also not permanent. If she puts in the effort, she can reach back out to her family members and establish bonds to provide her with a sense of security. Once developing insight into her current emotional state, Mrs. A. can be well on her way to becoming the independent, hard-working woman she wishes to be.
REFERENCES
Beck , A.T. (1983). Cognitive therapy of depression: New perspectives. In Treatment of Depression: Old Controversies and New Approaches ed. P.J. Clayton & J.E. Barrett. New York: Raven, pp. 265–290.
Ben-Itzhak, S., Bluvstein, I., Schreiber, S., Aharonov-Zaig, I., Maor, M., Lipnik, R., & Bloch, M. (2012). The effectiveness of brief versus intermediate duration psychodynamic psychotherapy in the treatment of adjustment disorder. Journal of Contemporary Psychotherapy, 42(4), 249-256.
Blatt, S. J. (1998). Contributions of psychoanalysis to the understanding and treatment of depression. Journal of the American Psychoanalytic Association, 46(3), 723-752.
Grav, S., Hellzèn, O., Romild, U., & Stordal, E. (2012). Association between social support and depression in the general population: the HUNT study, a cross‐sectional survey. Journal of clinical nursing, 21(1‐2), 111-120.
Hughes G. (2007). First do no harm; then try to prevent it. Emergency medicine journal : EMJ, 24(5), 314. https://doi.org/10.1136/emj.2007.047803
Jung, C. G. (2012). The Undiscovered Self: With Symbols and the Interpretation of Dreams (New in Paper). Princeton University Press.
Lorenz, L., Perkonigg, A., & Maercker, A. (2018). A socio-interpersonal approach to adjustment disorder: the example of involuntary job loss. European journal of psychotraumatology, 9(1), 1425576.
Murdock., N. L. (2017). Theories of Counseling and Psychotherapy: A Case Approach (Fourth ed.). Boston: Pearson.
Silverman M. A. (2017). ON THE BIRTH AND DEVELOPMENT OF PSYCHOANALYTIC FIELD THEORY, PART 1. The Psychoanalytic quarterly, 86(3), 699–727. https://doi.org/10.1002/psaq.12164
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