Psychoanalysis is one of the psychodynamic therapy methods and was developed by Sigmund Freud. At the centre of this type of therapy is a focus on unconscious conflicts, which the psychoanalyst is supposed to bring to resolution through interpretation.
Subsequent approaches to psychotherapy based on psychoanalysis are often called psychodynamic therapies.
The first beginnings of Freud’s psychoanalysis can be found in trauma theory. Freud ascribed unconscious traumas in childhood as representing the aetiology of “hysteria”. As a student of Charcot, Freud was able to observe the method of hypnosis and its symptom-relieving effect in “hysterical” patients and also used it with his patients. Through a hypnosis-induced altered state of consciousness, it is possible for patients to now remember the events that were unconscious. The moment when the trauma can be recalled is called catharsis (purification) by Freud, as the symptoms subside and are accompanied by affective stirrings. Freud assumed that beneficial emotional coping with the trauma did not take place in childhood. The aim of the treatment, the cathartic procedure, should therefore be the reliving of the trauma and the appropriate emotional coping.
However, since the symptoms often reappear after hypnosis and patients are again unable to remember aspects relevant to treatment, Freud developed a therapeutic approach with psychoanalysis in which therapy goals can be achieved without hypnosis. Freud changed his trauma theory to drive theory, because not every trauma was a real event, but partly represented fantasies and unconscious desires.
Drive theory is based on the realisation that much of the psychic content is hidden from consciousness. The idea of the existence of an unconscious is the foundation of all psychoanalytic theory.
Freud introduced the first topical model (also known as the iceberg model) for better understanding. As a topography of the soul’s life, Freud describes three domains:
the unconscious, the preconscious and the conscious.
Freud revised the model into the so-called structural model (also called the second topical model or instance model). Here, too, Freud describes three areas: the id, the ego and the superego.
Freud further describes drives as an “inner-somatic source of stimuli” (as distinct from external stimuli). These drives motivate behaviour and, according to Freud, can be divided into life and death drives. Life instincts bring about self-preservation or preservation of the species, while death instincts have death as their goal and express themselves in aggression.
Freud developed a developmental psychological model of the psychosexual phases to describe the development of human sexuality. Sexuality here means the general energy of the life drive, the libido. Thus, sexuality in psychoanalysis refers not only to the genitals, but to a general energy that strives for pleasure or satisfaction. For example, in the psychoanalytical sense, the intake of food is connected with sexual satisfaction. For this reason, the term infantile sexuality is often misunderstood: According to Freud, the development of infantile sexuality can be divided into different phases throughout the infantile years of life, in each of which an erogenous zone dominates psychosexual development. According to Freud, if the developmental phases are not mastered, disorders occur.
For the practice of psychoanalytic psychotherapy, the drive theory means that drives from the unconscious, the id, are the focus of therapy. To expose these, psychoanalysts work with methods of ego weakening. Such methods include:
free association (conscious elimination of self-censorship). Analysis of misperceptions (understood as a compromise between id and ego) or dream interpretation (during dreaming, the ego is weakened).
Psychoanalysts also create conditions in which the ego is weakened. For example, lying on the couch is said to be conducive to regression.
Anna Freud attached more importance to the ego and superego than her father and further developed theories about the ego. The ego must integrate the drives of the id, the internalised morality of the superego and the demands of reality. Unconscious desires from the id that the superego does not allow are experienced by the ego as threatening (and thus unpleasant) and attempted to be overcome through defence mechanisms. The defence mechanisms are not primarily used to defend against the drive, but to reduce the resulting unwillingness. If the ego cannot completely ward off the drive, this manifests itself in symptoms. Symptoms therefore always arise when drives cannot be fully acted out or completely warded off. Disorders and symptoms thus fulfil a function. The functional aspect of mental disorders thus also resembles the gain of illness. This insight is thus not only important for psychotherapy but also for psychosomatic treatment in particular.
Defence mechanisms can be divided into immature and mature defence mechanisms. The ego of a person with structural pathology (low structural level) uses immature defence mechanisms for drive defence. With this type, the drive defence takes place more in the area of interpersonal relationships, i.e. interpsychically. With a higher structural level, intrapsychic drive defence becomes possible by means of mature defence mechanisms and thus conflict pathology.
Ego psychology has changed the practice of psychoanalytic psychotherapy. In contrast to drive theory, ego weakening is dispensed with because the focus is not on the id but on the ego. Ego weakening would therefore be counterproductive, since it is precisely the ego that is the object of observation and should be treated.
Areas of application of psychoanalysis can be, among others, problems with finding one’s identity, interpersonal conflicts, depression or anxiety disorders. Other indications include dissociative disorders and personality disorders.
The patient’s personality and unconscious life history should be comprehensively analysed. The aim is not to quickly eliminate the symptoms but to change the patient’s existing structures and fixations.
Free association and dream interpretation, which should bring the unconscious to light, are particularly important in therapy. The processing of transference, counter-transference and resistance is also of decisive importance.
As a rule, low-frequency psychoanalytic therapy involves 1-2 sessions per week for 2-3 years. It can be done lying down or sitting up.
In high-frequency psychoanalytic therapy (psychoanalysis proper), sessions take place 3-4 times a week. A complete therapy can take more than 10 years. The therapist usually sits outside the patient’s field of vision while the patient lies on a couch. The lying position is intended to improve the patient’s relaxation and focus attention on his or her soul world. By promoting regression, a re-experiencing and reactivation of old mental conflicts is made possible.
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