INTRODUCTION "Look into the depths of your own soul and learn first to know yourself, then you will understand why this illness was bound to come upon you and perhaps you will thenceforth avoid falling ill."-Sigmund Freud
The development of the theory and practice of psychoanalysis has spanned more than a generation. The founder of psychoanalysis, Sigmund Freud, laid a sold psychological foundation for future psychoanalysts to build upon and improve. Donald Winnicott, a British pediatrician who spent time working with babies, provided analytical theories that described the results of good and bad caregiving. Edith Jacobson experienced the darker-side of human nature first-hand when she was placed in a Nazi concentration camp during World War II. Her own experiences and experiences of her patients led her to modify Freud’s instinctual drive theory. Harry Stack Sullivan, through his comprehensive study of schizophrenics in the 1920’s, believed that psychopathology could be traced back to one’s interpersonal field of experience. Finally, the contemporary analyst Robert Stolorow, believes that the world experiences of both the patient and the analyst (and how they mutually influence each other) are analytical focal points of inquiry. The innovation of Sigmund Freud’s psychoanalysis has progressed from a one-person psychology, to a dual-person psychology, to a new multi-person experiential psychology. Freud primarily attributed psychological development to intrinsic forces and drives. Winnicott, Jacobson, and Sullivan all emphasized the dual-person relationship between people as key components in the psychological development of a patient. Stolorow has aided in the present-day development of psychoanalysis by focusing his analytical inquiry on the experiential dynamics of the patient within a multi-person context. Interestingly, each of these analytical innovators drew upon the theoretical foundation of the father of psychoanalysis, Sigmund Freud.
CLASSICAL PSYCHOANALYSIS Sigmund Freud: Models of Personality
Sigmund Freud (1856-1939) continually based his theoretical framework of personality around his clinical observations. Through his clinical discoveries, he formulated three main theories of personality that included: (1) the topographic model, (2) the genetic model, and (3) the structural model. Each of these models attempted to explain the complexities of human personality and the causes of normal and abnormal psychological functioning. The topographical model was a map of the human mind. Freud believed that the mind was comprised of three realms: the unconscious, preconscious, and the conscious. The unconscious aspect of the human mind consisted of feelings and ideas that were not accessible to experiential awareness. Feelings and ideas that could eventually be accessed into awareness consisted of the preconscious realm of the mind. The conscious was the area of the mind where the immediate experiential awareness of feelings and ideas were stored. Mitchell and Black (1995) have explained that “As his clinical experience grew, Freud realized that what was most crucial to a permanent removal of symptoms was for the objectionable, unconscious material to become generally accessible to normal consciousness” (p. 5). However, Freud’s observations in the clinical setting found that patients exhibited what he described as a defense, which kept unconscious feelings and ideas out of awareness. The genetic model was a developmental stage theory of personality categorizing human biological instincts. Freud observed that the human biological instinct of sexually played an integral part in the psychological functioning of his patients. Sexual instincts, called drives, were viewed as internal stimuli that demand external discharge. These drives find their presentation in various tensions throughout areas of the body and require certain activities for adequate discharge. Specific areas of the body, or erogenous zones, are preeminent depending on a child’s stage of development and “…activity involving that zone becomes the central organizing focus of the child’s emotional life” (Mitchell & Black, 1995, p. 13). Prochaska & Norcross (2003) note, “For Freud, the stages of life are determined by the unfolding of sexuality in the oral, anal, phallic, and genital stages” (p. 31). At each stage, a child can become developmentally fixated or stuck, which leads to later psychopathology in adulthood. The structural model of personality was a detailed psychic map of the human mind. Freud believed that the mind was comprised of three distinct unconscious structures, called the id, ego, and super-ego. The id is defined as the storehouse for primitive desires and impulsive energies seeking immediate gratification. The ego is the part of the mind that regulates and controls the id’s primitive desires. The super-ego “…is a set of moral values and self-critical attitudes, largely organized around internalized parental images” (Mitchell & Black, 1995, p. 20). This structural model illustrated what Freud found in his clinical experience: Humanity is in a constant struggle between primitive impulses and social civility.Freudian Psychoanalysis Sigmund Freud believed that a patient had to undergo an analysis in order to unlock unconscious dynamics that were causing psychopathology in patients. The website Dictionary.LaborLawTalk.com brilliantly summarizes classical analysis: The basic method of psychoanalysis is the transference and resistance analysis of free association. The patient, in a relaxed posture, is directed to say whatever comes to mind. Dreams, hopes, wishes, and fantasies are of interest, as are recollections of early family life. Generally the analyst simply listens, making comments only when, in his or her professional judgment, an opportunity for insight on the part of the patient arises. In listening, the analyst attempts to maintain an attitude of empathic neutrality, a nonjudgmental stance designed to create a safe environment. The analyst asks that the analysand speak with utter honesty about whatever comes to awareness while interpreting the patterns and inhibitions that appear in the patient`s speech and other behavior (Retrieved June 29, 2005).Freud found that the technique of free association also brought out important past figures in the life of the patient. The analyst was viewed as that important past figure and he was related to, in accordance with the patient’s previous patterns of interaction. During the transference, McWilliams (2004) explains: When therapist and patient are together, with one party urged to report uncensored thoughts and feelings while the other is relatively quiet, patients have more than passing transference reactions; they tend to develop what Freud called a “transference neurosis”: a set of attitudes, affects, fantasies, and assumptions about the analyst that express central, organizing themes and conflicts dating from their experiences as children (pp. 14-15).Freud believed that the resolution of these conflicts were central to the alleviating psychopathic symptoms.
OBJECT RELATIONS: WINNICOTT The 1940’s was a time of dissention in the discipline of psychoanalysis in Great Britain. Donald Woods Winnicott (1896-1971) was a major contributor to the “independent”school of psychoanalytic thought that emphasized a “two-person” psychology. The traditional Freudian concept of intra-psychic forces primarily affecting the psychology of an individual was questioned by Winnicott. His influence has made a lasting impression, “…particularly in the more recent integration of object relations theory and interpersonal theory in current relational psychoanalysis” (Mitchell & Black, 1995, p. 138). D.W. Winnicott emphasized the relational dynamics of children with their mothers as major factors in an early development of the self. Winnicott found that a mother’s level of emotional support to her child was a primary contributor to a child’s sense of self. Mitchell and Black (1995) note that “Winnicott saw the quality of the infant’s experience of the earliest months of life as crucial for the emergence of personhood. It was the environment that the mother provided (not the child’s conflictual instinctual pressures) that determined the outcome” (p. 125). According to Winnicott, children go through important stages of experience determined by the emotional responsiveness of their mothers. In early childhood, a child experiences subjective omnipotence, whereby he gets what he wants. If the child is hungry, he’s fed by the mother. If the child is distressed by a stranger, he is comforted by the mother. The child experiences a moment of illusion anytime his wishes and desires are met by the mother. Eventually, the mother is not able to provide the instantaneous responsiveness that the child seeks. Over time, the mother slowly withdraws her continual response to the needs of the child within the context of a holding environment. This environment allows a space to emerge where the child can have his needs met yet also be protected without knowing it. During this time, the mother slowly becomes less responsive to the immediate desires of the child. Soon, the child begins to lose the moments of illusion and realize that it was not his desires that created satisfaction. Rather, the child starts to understand that the mother’s responses to his desires are what gave him satisfaction. Thus, the feeling of dependence by the child to the mother is first experienced. The child eventually learns that desires are met by a variety of individuals who also have their own independent desires. Alongside the subjective omnipotence of a child lies an objective reality, which constitutes the child’s awareness of separateness between himself and desired objects. While the subjective omnipotence experience is one in which the child feels that his desires create satisfaction, the objective reality experience is one in which the child independently seeks out objects of desire. In between the experience of subjective omnipotence and object reality of a child lies the transitional object. Winnicott believed that “the ‘transitional object’ is experienced as neither subjectively created and controlled nor as discovered and separate, but as somewhere in between” (Mitchell & Black, 1995, p.127). The child chooses an object, such as a blanket, to comfort himself during the time when the mother gradually becomes less responsive to the needs of the child. The object “…cushions the fall from a world where the child’s desires omnipotently actualize their objects to one where desires require accommodation to and collaboration of others to be fulfilled” (Mitchell & Black, 1995, p.128). Winnicott also formulated the idea of object usage to illustrate the experience the child undergoes whereby aggressive tendencies may be observed in the evolution from subjective omnipotence to objective reality. Mitchell and Black (1995) detail Winnicott’s object usage concept in the following summation: In subjective omnipotence, the child uses the object “ruthlessly.” He creates it, exploits it thoroughly for his own pleasure, and destroys it in his total appropriation of it. From a perspective outside the child’s subjectivity, this experience requires a mother who surrenders herself to and can survive being used this way. Gradually, the child begins to become aware of the other who survives his destruction of her. It is the cyclical process of omnipotent creation, destruction, and survival that begins to establish for the child some sense of externality, a real other who exists in her own right, outside his omnipotent control (pp. 128-129).The response of the mother during this time of object usage has a direct influence on a child’s emotional development. If the mother responds to the child’s usage of her negatively, such as failing to meet the needs of the child, “the result is a child afraid to fully need and use his objects and, subsequently, an adult with neurotic inhibitions of desire” (Mitchell & Black, 1995, p.129). Winnicott organized the responsiveness of the mother to the child and the child’s subjective experience in early infancy around the concept of good-enough mothering. If the mother provides an environment that enriches a child’s healthy sense of self by being responsive to his needs and mindful of his independent development, she is considered a good-enough mother. However, “when the mother is unable to provide the kind of good-enough environment necessary for the consolidation of a healthy sense of self, Winnicott felt, the child’s psychological development ceases” (Mitchell & Black, 1995, p.129). This not-good-enough mother activates impingement within the child, which arises out of either a child not getting desires met or not being supported along the path of the development of a healthy sense of self. Winnicott’s Clinical Approach Winnicott believed that the central focus of psychoanalysis should be the development of the self. The analyst becomes the good-enough mother that the adult patient did not experience early-on in life. Resembling the good-enough mother, the analyst seeks out the idiosyncratic desires of the patient. Through his clinical observations, “Winnicott saw the patient as powerfully self-restorative, shaping and molding the analytic situation to provide the environmental features missed in childhood” (Mitchell & Black, 1995, pp. 133-134). Interestingly, interpretations and analytic content were not important avenues in analysis, but rather relational experiences of the patient’s self in the therapeutic environment. Mitchell and Black (1995) conclude that “the analyst allows the patient to feel she has created him and, by not challenging that use of him, enable the patient to rediscover her own capacity to imagine and fantasize, to generate experience that feels deeply real, personal, and meaningful” (p. 134).
EGO PSYCHOLOGY: EDITH JACOBSON Edith Jacobson (1897-1978) was a major contributor to the ego psychology movement that became a flourishing perspective within psychoanalysis in the United States beginning in the 1940’s. Jacobson revised Sigmund Freud’s structural model of personality (the id, ego, and superego) with her own theoretical developments. Principally, Jacobson modified Freud’s instinctual drive theory to include the “…interplay between actual experience and drive development” (Mitchell & Black, 1995, p. 50). Jacobson viewed biological drives as being directly influenced by the early experiences of caregivers. If the early experiences of children are satisfying, healthy libidinal drives are fostered. On the other hand, if the early experiences of children are plagued with frustration, “…a more powerful and intense aggressive drive will consolidate that distorts the still vulnerable normal developmental processes” (Mitchell & Black, 1995, p.50). The early experiences in childhood that affect the drives impact the ongoing development of the self. A contented self develops when a child continually experiences a mother who is kind, caring, and in-tune with his emotional needs. Yet, when a child has experiences of continual frustration and perceives the mother as frustrated, hostile, and unattended to his emotional needs, a frustrated self emerges. These early experiences provide a template for future experiences in the interaction with others in the world of the adult patient. Jacobson stressed the importance of assimilating feeling states in the developmental process. Since there are times when a child sees his mother as kind and caring but also frustrating, it is inherent that he blend his feelings of love and hate. The blending of his feeling states blocks the strong primitive drives of libido and aggression and allow for a more mature emotional development. Mitchell and Black (1995) describe Jacobson’s emphasis on the importance of the assimilation of feeling states in the following passage: The attainment of affectively integrated images of self and of other allows a greatly increased capacity for more complex experience: an ability to register differences between one’s emotional state and that of an important other; graduations in emotional response enhancing capacities to think and to learn that are jeopardized by unqualified acceptance or complete rejection; the ability to be disappointed by someone but still love her; and tolerance of anger without an internal collapse and a loss of a sense of one’s being worthwhile or loving (p. 51).Thus, the assimilation of feeling states plays an integral part in the emotional maturation of a child. Jacobson also re-formulated Freud’s concept of the super-ego. Freud believed that the super-ego developed from castration anxiety in the oedipal stage of development. It was his view that psychosexual dynamics result in the formation of the super-ego. Specifically, he felt that “The moral agency in the boy’s psyche is thus directly instigated by his fear of castration and effected by an identification with the prohibitive and aggressive aspects of his father” (Fancher, 1973, p. 213). Jacobson, on the other hand, viewed the development of the super-ego as arising out of the experiences with others, not psychosexual dynamics. The earlier experiences of a mother prohibiting certain behaviors of her child lead to the development of his super-ego. Jacobson’s conception of the superego was “…thus rendered more broadly dependent on the complex interpenetration between passions and experiences with others” (Mitchell & Black, 1995, p. 52). Jacobson’s Clinical Approach Edith Jacobson’s ego analysis involved the inquiry into a patients’ developmental past. This inquiry is sought in the transference between the patient to the analyst in a therapeutic relationship. Mitchell and Black explain: Particularly with more disturbed patients, the transference came to be understood not only as expressive of forbidden longings but as an arena within which remnants of ill- fated attempts at building normal psychic structure could be discerned in particulars of the relationship that the patient established with the analyst. By attending to specific features of the experiences and images that emerge in this relationship, and using them as indicators of the fate of important developmental processes, the analyst could determine which aspects of psychic structuralization had been compromised and, with the patient, develop a verbal account of what went wrong in the patient’s early experience, using this very processing as an aspect of repair (p. 53). Thus, unlocking the past dynamics of the developmental past through the transference was absolutely necessary in bring therapeutic change to a patient.
INTERPERSONAL PSYCHOANALYSIS:HARRY STACK SULLIVAN Harry Stack Sullivan (1892-1949) was a pioneer and major contributor of interpersonal psychoanalysis. Sullivan believed that psychoanalytic inquiry should concentrate on the past interactions of a patient in order to understand present psychopathology. The individual personality is shaped and molded by lifelong interactions, starting with caregivers in infancy. Clinically, Mitchell and Black (1995) add that “his formulations were explicitly concerned with the development of psychopathology and the response of the self in difficulties in living” (p.70). Sullivan was particularly interested in the early experience of anxiety in infants. In the earliest stages of infancy, children’s needs are met by integrating tendencies, which are needs for satisfaction that are given on a mutual basis. The mother supplies comfort, warmth, and emotional expression which are responses to the child’s basic needs. These needs are intrinsic, biologically-based, yet anxiety is external and socially-based. The feeling state of anxiety in caregivers and other important figures in a child’s life is perceived by them and is transmittable. Children are easily affected by anxiety in others and become anxious themselves when they are in contact with them. The ALLPsychonline website illustrates this interaction: According to Sullivan, mothers show their anxiety about child rearing to their children through various means. The child, having no way to deal with this, feels the anxiety himself. Selective inattention is soon learned, and the child begins to ignore or reject the anxiety or any interaction that could produce these uncomfortable feelings. (Retrieved June 28, 2005). In the early experience of a child, anxiety also has a profound impact on the child’s perception of the mother and father. The child categorizes the perceptions of his parents and other important caregivers into anxious and nonanxious states, which the child collectively perceives as the ‘good mother’ or ‘bad mother.’ Sullivan emphasized that what was important for the child was not whether the caregivers where actually the child’s parents, but whether or not the caregivers in the child’s world displayed anxiety. The child soon begins to learn that he can foresee whether the good mother or the bad mother is approaching him. Experiences in “facial expression, postural tension, vocal intonation become reliable predictors of whether the baby will find himself in the hands of someone who calmly responds to his needs, or at the mercy of someone who draws him into a maelstrom of unrelievable stress” (Mitchell & Black, 1995, p. 68). Over time, the child begins to learn that the arrival of the images of the good mother or bad mother have to do with his own behavior. Once the child realizes that his own behavior can affect the images of good mother and bad mother, the child begins to form a sense of self. Sullivan felt that anxious states in caregivers, caused by a child’s behavior, are generated into a child’s sense of ‘bad me.’ Conversely, behaviors and actions by a child that produce praise and approval from caregivers are generated into a child’s sense of ‘good me.’ Thus, Sullivan proposed that anxiety is a key component in the molding of self by the interactions that arise with important caregivers. The child’s sense of self further progresses through an organized self-system. This self system “…steers activities away from gestures and behaviors associated with rising anxiety in the child’s caregivers (and there also in himself) and toward gestures and behaviors associated with decreasing anxiety in his caregivers (and therefore also in himself)” (Mitchell & Black, 1995, p. 69). A child’s self-system is fluid, not fixed, developing from experiences that are familiar to the child. Eventually, the child desires to form new relationships with others that are arisen out of new needs of satisfaction. When the child reaches the age of four or five years old, he desires to have friends outside the parental realm. At the preadolescent ages of nine to eleven, the child begins to find a central ‘best friend’ that he can confide in. In adolescence, the teenager begins to seek out relationships that can provide sexual and emotional intimacy. When a new need arises, the self-system of the child is re-aligned to accept new and important relationships that are instrumental to the interpersonal psychology of the child.Sullivan’s Clinical Approach Harry Sullivan’s clinical emphasis was on a patients’ sense of self in relation to their interactions with others. Mitchell and Black eloquently summarize the techniques involved in interpersonal psychoanalysis: One of the central techniques of the interpersonal psychoanalyst is to increase awareness of the operations of the self-system by asking questions and encouraging self-reflection, so that crucial, rapid sequences can be observed, understood, and, through understanding, gradually altered” (p. 71). Insight and understanding are also key components for change in Sullivan’s interpersonal psychoanalysis. Since “the more the patient understands the workings of the self-system in its efforts to avoid anxiety, the more easily that patient can make different choices, Sullivan believed” (Mitchell & Black, 1995, p. 74). The interpersonal analyst also spends a great amount of time inquiring into the past interactions of his patients. By doing this, “the patient attempts to draw the analyst into his characteristic forms of interaction. The analyst, like a sensitive instrument, uses her awareness of these subtle interpersonal pulls and pushes to develop hypotheses about the patient’s security operations” (Mitchell & Black, 1995, p. 79).
INTERSUBJECTIVITY: CONTEMPORARY PSYCHOANALYSIS Intersubjective psychoanalysis is a relatively new theoretical model that is gaining prominence in psychoanalytic academia and practice. Intersubjectivity in psychoanalysis is simply defined as: The notion that the analyst and analysand can mutually shape the conscious and unconscious experience of the other. According to this view, the analyst can never be detached and purely objective observer; instead, he or she is constantly involved in a conscious and unconscious interplay of ideas as well as affective and symbolic communications (Diamond & Marrone, 2003, p. 14).The leading advocate of this psychoanalytic approach is the clinical professor and professional analyst, Dr. Robert Stolorow. Stolorow incorporates many of the concepts of object relations theory, ego psychology, and interpersonal psychoanalysis into his own formulations. However, Stolorow builds on these models by explaining that a patient’s entire experiential world is examined in perspective rather than just the interactions between a patient and another influentialperson. In his co-authored book entitled Worlds of Experience: Interweaving Philosophical and Clinical Dimensions in Psychoanalysis, Stolorow discusses how his model focuses on the subjective affectivity of a patient. He explains: It is our contention that a shift in psychoanalytic thinking from the primacy of drive to the primacy of affectivity moves psychoanalysis toward a phenomenological contextualism and a central focus on dynamic intersubjective systems. Unlike drives, which originate deep within the interior of a Cartesian isolated mind, affect is something from onward is regulated, or misregulated, within relational systems. Therefore, locating affect at its center automatically entails a radical contextualization of virtually all aspects of human psychological life (Stolorow, Atwood, and Orange, 2002, pp. 10-11).
Stolorow’s Clinical Approach In Stolorow’s clinical process of intersubjectivity there are three main focal points of inquiry: emotional convictions, self-reflexivity, and reality. The embodiment of emotional convictions are examined by the analyst, which arise out of a patient’s life-long experience in the world. Stolorow believes that these convictions are mostly unconscious and need to be brought to consciousness for a healthy reflection and interpretation. Reflection and interpretation, in turn, allow the patient to actualize their entire sense of self over time. The analyst, on the other hand, must have the capacity for engaging in self-reflexivity. He must be aware of his own world-view and biases in the clinical environment. Self-reflexivity is further defined by Stolorow: Second, aware that our theories embody our own historically shaped emotional convictions and themes, we must hold light whatever perspective we may have on the patient’s troubles and remain ready to question our cherished psychoanalytic theories of human nature with their associated views of psychopathology and cure (Stolorow, Atwood, and Orange, 2002, p. 118).The final focal point of intersubjective inquiry involves the notion of reality. It is essential for the analyst to attend to the reality of the patient and not to overshadow the reality of the patient with their own. By being mindful of the reality of the patient, the analyst is able to get a complete picture of the intersubjective world of the patient and proceed with a healthy analytical discourse.
CONCLUDING THOUGHTS In conclusion, the past hundred years have seen a major innovation in the theory and technique of psychoanalysis. Sigmund Freud, the father of psychoanalysis, provided the theoretical and clinical foundation for other psychoanalytic practitioners to draw on and develop. Each psychoanalytic innovator, including Winnicott, Jacobson, Sullivan, and Stolorow all have based their theories on their own clinical experience. Psychoanalysis has evolved from a one-person psychology, to a two-person psychology, and now to a multi-person psychology. Currently, the psychoanalytic community is being challenged by the mainstream psychological institution: the American Psychological Association. In the February 2005 issue of the Monitor on Psychology, the new APA president, Dr. Ronald Levant, explains why he is putting together a commission on evidence-based psychotherapy. He explains that the commission is being set-up “to affirm the importance of attending to multiple sources of research evidence and to assert that psychological practice based on evidence is also based on clinical expertise and patient values” (Levant, 2005, p. 5). The psychoanalytic community should not be overly concerned with evidence-based treatment. The analyst, Dr. Doris Silverman (2005), brilliantly explains: We consider, as well, the unique personality of the patient, including his or her special psychological problems, social characteristics, and cultural context, as well as the individual’s goals and values. Our current task force is using these features of our understanding of clinical practice to refine our definition so that it reflects our current knowledge and judgment about improving the health and well-being of the public (p. 310).Modern psychoanalytic theory incorporates all aspects of the psychological, social, and cultural dynamics of an individual in analysis. Thus, evidence-based treatment will provide future psychoanalytic developments with a pragmatic template in which to progress.
REFERENCESAllPsychonline: The virtual psychology classroom. Retrieved June 28, 2005, from http://allpsych.com/personalitysynopsis/stack_sullivan.htmlDiamond, N. & Marrone, M. (2003). Attachment and intersubjectivity. London, GB: Whurr Publishers.Dictionary.LaborLawTalk.com: Psychoanalysis. Retrieved June 29, 2005, from http://encyclopedia.laborlawtalk.com/PsychoanalysisFancer, R.E. (1973). Psychoanlytic psychology: The development of Freud’s thought. New York, NY: W.W. Norton & Co.Levant, R.F. (2005). Evidence-based practice in psychology. Monitor on Psychology, 36, 5.McWilliams, N. (2004). Psychoanalytic psychotherapy. New York, NY: Guilford Press.Mitchell, S.A. & Black, M.J. (1995). Freud and beyond: A history of modern psychoanalytic thought. New York, NY: Basic Books.Prochaska, J.O. & Norcross, J.C. (2003). Psychoanalytic therapies: 5th edition, Systems of psychotherapy (pp. 25-62). Pacific Grove, CA: Brooks/Cole.Silverman, D. K. (2005). What works in psychotherapy and how do we know: What evidence- based practice has to offer. Psychoanalytic Psychology, 22, 306-312.Stolorow, R.D., Atwood G.E., & Orange, D.M. (2002). Worlds of experience: Interweaving philosophical and clinical dimensions in psychoanalysis. New York, NY: Basic Books