Psychoanalytic Theory and Psychodynamic Counselling

1The talking cure

In the early 1880s the Viennese physician Josef Breuer treated a young woman, known in the case reports as "Anna O.", whose symptoms included paralysis of an arm and losing the ability to speak her own language. Breuer found that her symptoms seemed to ease when she talked about distressing memories; she herself called it "the talking cure". His younger colleague Sigmund Freud built on such cases to create psychoanalysis, the first major theory of counselling and psychotherapy. Almost every later approach in this unit either developed from it or was a reaction against it. (Historians have since found that Anna O. was not cured as completely as the published case suggested, an early warning about relying on single case studies.)

21. Freud's model of the mind

Freud described three levels of awareness: the conscious, the preconscious and the much larger unconscious (Figure 1). He also described three parts of the personality:

• the id, present from birth, which seeks immediate satisfaction of instincts (the pleasure principle);
• the ego, which develops to deal with reality, finding realistic ways to meet the id's demands (the reality principle);
• the superego, the internalised rules and ideals of parents and society, experienced as conscience and guilt.

When the demands of the id, the superego and reality conflict, the ego feels anxiety and uses defence mechanisms (Unit 6, Lesson 4) such as repression and denial. Freud also proposed that children pass through psychosexual stages (oral, anal, phallic, latency and genital), and that problems at one stage could leave lasting "fixations". This is the part of his theory with the least scientific support.

Figure 1. Freud's "iceberg" model of the mind. The ego and superego reach from consciousness down into the unconscious; the id is wholly unconscious. It is a metaphor, not a map of the brain.

32. Psychoanalytic and psychodynamic techniques

Classical psychoanalysis involved lying on a couch, several sessions a week, for years. Modern psychodynamic counselling is usually face to face, once a week, and often brief (for example 16 to 30 sessions). It focuses on recurring patterns in relationships: a client who keeps expecting to be abandoned may come to see how early experiences shaped that expectation, and test it in the safer relationship with the counsellor.

43. Evaluation

• Testability. The philosopher Karl Popper argued that psychoanalysis cannot be falsified: any outcome can be explained after the event (if a client accepts an interpretation it is correct; if she rejects it, that is "resistance").
• Evidence base. Freud built his theory on a small number of case studies, mostly of well-off people in Vienna, interpreted by Freud himself. In the case of "Little Hans" (1909), Freud worked mainly through the boy's father, who was a supporter of his ideas.
• Effectiveness. Modern psychodynamic therapy has been tested in controlled trials. Reviews (for example Shedler, 2010) find that it helps with depression, anxiety and some personality disorders, with effects broadly similar to other therapies, although critics argue some of these reviews were too generous.
• Lasting contributions. Unconscious processes, defence mechanisms, the influence of childhood, and the therapeutic relationship (transference) remain important ideas in counselling, even among counsellors who reject much of Freud's theory.
• Practical limits. Long-term therapy is expensive and time-consuming, and requires highly trained therapists, which limits its use in most of the world, including Rwanda.