What is Psychodynamic Therapy?
Sigmund Freud
We knew even in Freud’s time (1856 - 1939) of the connection between brain and behavior. In ancient times, psychic disturbances were considered evidence of demonic possession. The most organized forms of psychiatry were based on head shape, body shape, and bodily fluids, trying to make sense of the mind based on external logic of the body. This reasoning makes sense, and is a sensible frame for body-based principles in modern psychotherapy which is incorporating greater emphasis on the mind-body connection. Freud was actually a neurologist – he originally hoped to construct a neuro-physiological theory of mental mechanisms, intending to explain behavior based on the physical matter of the brain and body. Psychoanalysis was born because his thinking from the start always sought to integrate several different systems of bodily functioning as all influencing the individual’s behavior.
Freud attempted to reverse engineer a solution from a problem – he was looking for a way to treat obsessive (neurotic) and hysterical symptoms that seemed to have no neurological explanation. Noticing that many aphasic children had no apparent organic cause for their symptoms, the basis of Freudian psychodynamic therapy for the mind was born. One man had the insight simply that not all thinking is conscious. The idea of the conscious necessitates the possibility of the unconscious.
How could there be unthought thoughts? Could there be memories that weren’t remembered, feelings that weren’t felt? Psychoanalysis is predicated on the idea that if you aren’t thinking your thoughts, you have to go find them. If you aren’t remembering your memories, you have to restore them and if you aren’t feeling your feelings, you have to stop blocking them. The “talking cure” explored all these avenues with the presumption that the root was emotional trauma. After all, behavior is concrete, external. Emotions and thoughts and abstract and internal. It logically follows that unexplainable behavior comes from something that’s real that you can't see. Hysteria, neuroses, and sexual deviancy in waking life must have some connection to the state of mind capable of sleep, hypnosis, anesthetic paralysis, and dreaming.
The Psychosexual Theory
Symptoms of psychic disturbance are generally incongruent to the expression of the self the individual believes to be acceptable to others. Healthy adaptation is based on the ability to successfully function in society. Freud believed the Victorian-era attitude toward sex and sexuality (1837 - 1901) caused sexual experiences and wishes to be made unconscious and repressed out of psychic awareness. Working to conform behavior to societal expectations conflicted with the needs of sexual gratification and this conflict of drives caused symptoms of anxiety. One’s options were to either live in a way society condemns, or repress the impulses. His formulation of the unconscious was reflective of the time in which it was conceived, and why his early work so heavily emphasized sexual originations and development.
Freud started with the answer - “Sexual repression and distressing experiences of a sexual nature are the root of psychic disturbance” - and assumed it fit the questions - “what’s wrong with me?” He worked from the position of confirmation bias and practiced in a way now recognized as leading, assuming the answer then asking questions designed to find evidence to fit. He probed if the patients had been sexually abused, positing that unconscious fantasies secretly caused unacceptable excitation that had to be disavowed. Criticized for misinterpreting or influencing these recollections, he moved to adopting the view that the same disavowal was caused by infantile masturbation, not necessarily abuse. This gradually morphed into the Oedipus complex, a phase of development marked by the son’s desire for love and nurturance from his mother being experienced as sexual attraction, and subsequent jealousy that his father can have sex with her. He abandoned and transformed his views multiple times, as well as privately acknowledged that he no longer supported the “seduction theory” of psychopathology.
Oedipus Rex by Pierre-Auguste Renoir
Many people today discount Freud wholesale because several of his views on the role of sex have since been disproven or articulated by more valid theories. But the fact that he worked from the assumption that his premise was correct shows thinking in terms of theory, not logic. Logical thinking observes the link between events: if X, then Y. Theoretical thinking seeks to explain the unseen why of events, things that cannot be observed. The same thing that caused some of his big missteps is ultimately what made him unparalleled in the field – he began with a big picture and worked to see how all the pieces fit. This is top-down thinking and requires not only the ability to hypothesize how abstract concepts influence outcomes but the open-mindedness to adapt and adjust to the evidence rather than simply discarding it when it doesn’t fit. It requires the ability to see how the layers underneath work. Theoretical thinking is the only way to generalize universal truths that aren’t dependent on the individual or the particular circumstances of their concrete reality. When the pieces underneath always work the same, you can predict the outcome of changing specific variables. But the theory has to be sound first.
The psychosexual stages of early childhood development correspond essentially to the child’s discovery of each pleasurable excitation of the body: oral feeding, anal constriction, and genital excitation explicitly. Although Freud eventually became dissatisfied with the idea of only sexual motivations for behavior, the foundation of repression as based on the need for societal adaptation remains the root from which all of psychoanalysis logically follows. That we want things that are inappropriate to express encapsulates all the meaning in what we consciously and unconsciously do – in itself the Freudian slip!
Ultimately, the psychosexual era led to three meaningful ideas: dreams have symbolic significance as an expression of the unconscious, distressing experiences can be repressed from conscious awareness, and bodily pleasures contrasted with societal mores shape behavior. These three pieces led to three big wholes: sexual repression resulted in the Oedipus complex. The content of dreams resulted in primary process thinking, diffuse, unintegrated, visual and mental symbolic antecedents to the conscious thought of “secondary cognition.” The repression of distressing experiences generally resulted in the “System Unconscious,” an autonomously operating system that contained the repressed contents that were kept out of conscious awareness. He concluded the mind is “topographic,” and that existence is experienced in different layers. Those that are preoccupied with the lower emotional and unconscious layers will predictably have difficulty accessing the higher layers of more sophisticated thought. Psychosexual theory identified one generalized universal facet that defines human nature: the pleasure/pain binary. Every individual is motivated by a higher or lower expectation for experiences of pleasure or pain.
On Freud’s “On Narcissism”
One of the persistent frustrations in the field of psychology are the misunderstandings of its concepts by the average person. Narcissism as a concept is by and large greatly misunderstood by the public. Freud’s founding conception of narcissism had nothing to do with attention-hoarding, grandiosity, or status-seeking. In Freud’s conceptualization of repression, he believed the energy of unconscious sexual wishes transformed into the symptoms of hysteria and neurosis because they could not be expressed; the energy had to go somewhere and get out some way, and so it came out as disturbing eruptions. Narcissism meant that the cathexis of that energy – the direction it was focused – withdrawn from the other and directed back into the self. This would eventually form the basis of the second great binary of human duality, whether one’s libidinal emotional energy is primarily oriented toward the self or towards others, and directed inward or outward.
Echo and Narcissus, John William Waterhouse
In the aftermath of World War I, Freud’s depressed and self-destructive patients made him broaden his scope. Instead of directing destructive energy toward others, people directed it toward themselves. Instead of receiving sexual pleasure, some preferred to receive it from pain as in sexual masochism. In looking at mourning, he determined guilt was a turning inward of anger, attacking the self resulting in depression. The idea that emotional energy could be cathected inward or outward, toward the self or toward the other, meant that emotions could serve an inverse effect. This sparked the “dual drive” theory of sexuality and aggression, that some behavior is driven by conflicting motivations for the same aim. The tripartite self of the id, ego, and superego was born as the structure of the topographic mind. The id was perceived to be of primitive base impulses, and the superego of high-minded ideals. He viewed humans as having a central conflict of drives, the restrictive repression of the superego and the indulgent excesses of the id, moderated by the overarching ego which contained both. Drives are either gratifying or frustrating, and both serve a purpose for wish fulfillment, as some wishes must be frustrated in order to adapt to society and meet long term goals. Frustration of drives can be in itself a gratification.
Recognizing that the unconscious system was just as organized and autonomous as the conscious system meant recognizing there had to be mechanisms that built and maintained its functioning. Freud decided that repression was only one of many defense mechanisms. The contents of primary process thinking are symbolized visually, formed from emotions and somatic perceptual input before cognition forms and organizes, and before language as been acquired. Defense mechanisms work to keep the anxiety of recognizing their conflicting drives from working to integrate. Repressed out of conscious awareness, they have not transmuted through cognition and transformed into the cognitive symbols we recognize with words. The recognition of these symbols is felt bodily however, and was learned through the human relatedness of mirror neurons, another unconscious process. To recognize the presence of the conflict consciously would require sorting out the true wish from what denies its acceptance, so instead of integrating together both sides of the conflict continue to influence the person. The drives are not recognized and a bias toward action, of gratifying or frustrating the need, cannot be made. The person remains conflicted.
The intrapsychic conflict of drives causes the anxiety of primary process wishes. Symptom expression, then, was both the cause of and relief of the anxiety. Different types of psychological problems could then be explained in terms of what is being represented in the conflict of drive, anxiety, reality, and defense. Intrapsychic conflict exists in terms of gratification of the self, which frustrates the other, or gratification of the other, which frustrates the self. Difficulties resolving conflict are common in those with dysfunctional development of Freud’s second great binary of human nature represented here, the internalization of the boundaries between the self and the other. Psychopathology forms here when the individual cannot adapt to meet his own needs while maintaining relationships with others and in the world at large.
From Psychoanalysis to Psychodynamic
Today, a hierarchy of defense mechanisms has been identified and organized in terms of representing mature, neurotic, and primitive ego development. Once a patient’s level of defensive functioning has been identified, it is possible to deduce how integrated their cognition is and how dominant their primary process influences are to their functioning. Freud’s dual binaries, beginning with conscious/unconscious, have defined psychiatric understanding of the mind: every person biases on one side of the three major binaries of pleasure/pain, self/other, and inner/outer reality. Theodore Millon of the Millon Multiaxial Clinical Inventory, a diagnostic tool for assessing personality disorders, identifies the inner/outer binary as passive/active. Mentalization-based therapy also adds implicit and explicit mentalization, representing automatic unconscious thinking and manual, explicit cathexis. MBT also directly includes a cognitive/affective binary under the view that in disturbed personalities, the individual cannot access one of the poles when they are in a disturbed state.
Freud’s work focused on the neurotic personality, which forms due to failed resolution of the Oedipus complex and happens later in development, around age 7. It wasn’t until the end of his life that he turned his attention again to the stages of psychological development before that. He died just as he began to again question another basic assumption: it was taken for granted the idea that the ego was always synthetic, whole. What if the ego could be split? Object relations theorists like Melanie Klein, D.W. Winnicott, Ronald Fairbairn, and others took up the baton from there, continuing to identify the elements present in the psychodynamic orientation of the mind’s contents. These views have all been largely subsumed into the overarching structural personality orientation.
Structural theory has progressed from Freud’s tripartite self to identify 5 levels of personality organization, 3 organized at the borderline level indicating a psyche which remains split and unintegrated; the drives of gratification and frustration remain too conflicted to integrate.
Although Freud considered the neurotic ego the healthiest, we disagree with this view (and assume in time Freud’s views would have evolved as well). We also have a different perspective as to the binaries of human nature, as our independently conceived Ego Integration Theory is based on a formalized sequential process of ego development. We agree with structural theory’s five organizations of personality and consider the normative path of development to result in a fully integrated ego which has internalized all of the poles of mentalization and uses mature defenses, not defense mechanisms; the whole ego itself serves a protective function over the consolidated self, phasing out repression-based defenses with no aspect of experience defended out of consciousness. Psychopathology occurs due to psychological arrest in the attempted acquisition of one of the five binaries corresponding to each level of personality organization: in our view survival/death, active/passive, internal/external, self/other, and cognitive/affective. Successful completion of the separation and individuation of the ego results in a unified multidimensional subjective experience of reality which can access and analyze all aspects of experience through balanced use of every pole, knowing the self and others inside out. We emphasize the mechanism that hinges each pole to the next is integration of both poles of a binary mediated through another, most crucially the internal/external dimension. This creates a stack which operationalizes the dual drives. We believe this constitutes the missing piece of Freud’s puzzle that unifies the construction of the mind as a whole.
