Psychoanalytic theory: foundations and key concepts

¶ … Theory

Classical psychoanalysis is the most challenging of all the psychotherapies in terms of time, cost and effort. It is usually conducted with the patient lying on a couch and with the analyst seated out of his/her sight, to hear what the patient has to say. The treatment sessions last about 50 minutes and are normally held four or five times a week for at least three years. The primary technique used in psychoanalysis, as well as in other dynamic psychotherapies, which consists in permitting the unconscious material to enter the consciousness of the patient, is called "free association."

According to Freud, the patient "is to tell us not only what he can say intentionally and willingly, what will give him relief like a confession, but everything else as well that his self observation yields him, everything that comes into his head, even if it is disagreeable for him to say, even if it seems to him unimportant or actually nonsensical. The difficulty of the procedure stands in the fact that for a person to speak his/her inner thoughts is a departure from years of trying to conceal them to others. Free association also present difficulties because the patients find it hard to remember repressed feelings or experiences, which are related to intense and conflicting emotions never resolved.

Attentive listening and empathy from the therapist allows the patient to express thoughts and feelings which will later allow for the discovery of underlying emotional conflicts. During treatment, the patient will try to "blame" someone for the distress he/she feels, and this person if often the psychoanalyst. This is how patients often arrive to having all sorts of feelings, ranging from love to hate and from rivalry to rejection toward the psychoanalyst. This process, the projection onto the psychoanalyst of behaviors and feelings that have originated in earlier relationships is referred to as "transference." The manner in which the analyst handles the transference is crucial to the success of the psychoanalysis. The general conception is that the patient discovers the nature of his/her unconscious feelings and then becomes able to acknowledge them. The therapist directs the patient's attention to important aspects, of which he/she seems unaware, usually relating to links between the past and present, the emotional responses to the therapist and the important people in the patient life. These feelings are then regarded in a much more dispassionate way and from a tolerant perspective, as the patient feels liberated from their influence in future behavior.

The patient gradually learns to trust the therapist and becomes increasingly able to talk candidly and sincerely about his/her most intimate feelings and thoughts. Individual dynamic psychotherapy is also similar to psychoanalysis but involves a less formal environment, as the therapist and the patient are seated, so eye contact may be achieved.

It is certain that, in these conditions, that the relationship between the therapist and the patient is very close. Psychoanalysis allows the therapist to go very deep into the soul of the person he/she is treating. Therefore, the social and ethical aspect strongly influences the bond between the two. Used in social work, psychoanalysis may present a series of contradictions and may even prove harmful to the final purpose of helping people, in some cases.

2-How theory fits with the Life Model Schema: life transitions, environmental stressors, interpersonal obstacles. If it does not fit schema, explain where incongruities exist.

Psychoanalysis has dealt with issues such as life transitions, environmental stressors and interpersonal obstacles for a very long period of time. Although its specific methods are not always similar to those of affiliated sciences, such as psychology or psychiatry, when it comes to social work, psychoanalysis may prove extremely useful in treating those illnesses that are unapproachable for the other psycho-sciences, due to their nature.

Psychoanalysis, at least in its Freudian form, concentrates on the individual and the early development stages, without considering environmental factors as much as psychology, for instance. Interpersonal obstacles are attributed to a lack of adaptation to social norms, produced by internal factors in the individual, and not by the inadequacy of social factors.

However, these elements are not totally alien to psychoanalysis. Modern research has taken into consideration all the conditions that may influence the mental health of the patient, while concentrating on the inner self of the individual. This is why it is now used on a large scale in social work - it provides a unique insight to a person's soul. Therefore, any incongruities that may appear should be overseen and integrated into the larger goal of helping people.

3- Discuss compatibility of theory with social work values, ethics and skills; as well as the theory's relation to a strengths perspective in social work.

Normal behavior means acceptance of certain more or less specific ethical values which influence, direct and motivate behavior. (Papanek, 1991). Adults are often confronted with important choices regarding various situations, and the decision they take is determined by the consequences of this decision. If such decisions involve other persons, it is imperative to assess the ethical issues at hand in order to avoid harming others or even oneself.

The system of ethical values existing in each individual cannot simply be taken from society, since the provided frame of reference must be adapted according to the needs and desires of every individual. Therefore, many psychotherapists are afraid to indoctrinate, influence or judge the patient in accordance with their own system of values, as an effect thereof would be depriving the patient of independence or self-realization.

Psychotherapy may be viewd as "adjustment therapy," the term "adjustment" referring to any type of values which the therapist manages to identify. The approach also depends on the convictions of the therapist. One might have as a goal the patient's adjustment to accepted social values, while another might believe that mental health includes a slight form of rebellion against society.

Whether he/she wants it or not, the therapist exerts in the vast majority of cases a formidable influence on the patient, by using both verbal and non-verbal communication. It would seem that every patient becomes after a more or less short period of time a "therapist addict." As I have mentioned above, as an effect of the transference process, the patient desires to be accepted by the therapist and, as a consequence, he/she will be influenced in the performed actions by what the therapist views as acceptable behavior.

The therapist should have firm convictions regarding the patient's right to own values and respect for the differences between them. The patient may have religious values or ethical values different from those of the therapist. Another area in which differences are hard to avoid is the one of family setting and sexual morality. However, the therapist must remain objective, must think rationally and "must accept and respect the patient's integrity and values, if these are genuinely held and directed toward social feeling."

General directives of behavior build a frame of reference for each individual, who has thereby the chance to complement his/her own set of ethical values, according to the expectations of each person. Psychotherapy, whether in the form of individual or group therapy, is faced with the problem of directing the patient toward mental health by inducing a social feeling and the corresponding ethical values. The therapist must strongly believe that social interest is worthwhile and natural and that his/her tolerance of the patient's set of values, as long as they remain generally acceptable, helps the patient recover more rapidly. The patient, who has in the beginning a shaky set of values, becomes healthier and integrated into society.

The assumption the strengths perspective makes is that humans have the general capacity for growth and change, which corresponds to humanist approaches to social work. This "life force," as some authors have names it (Weick, 1992 cited by Early, GlenMaye), or "the human power," as have others, (Smalley, 1967 cited by Early, GlenMaye), is the drive that constantly transforms and heals. Since the individual has the capacity to grow, change, and adapt, it may be inferred that, since families share many of the qualities of individuals, they have the same characteristics.

As a consequence, both families and individuals have a wide range of capabilities, abilities, and strengths. Each individual has some degree of experiences, characteristics, and roles, which contribute to the personality of that particular individual. (Saleebey, 1997a; Weick, Rapp, Sullivan, & Kisthardt, 1989, sources cited by Early, GlenMaye). Correspondingly, "Families have traditions, rituals, and the combined capabilities of family members. Families also share the strengths of other systems in which they are embedded, such as extended family and neighborhood.

From an empowerment perspective this means that families already are competent or they have the capacity to become competent (Dunst, Trivette, & Deal, 1994, sources cited by Early, GlenMaye). The strengths approach attempts to understand clients in terms of their strengths. This involves systematically examining survival skills, abilities, knowledge, resources, and desires that can be used in some way to help meet client goals. "

Another characteristic assumption to the strengths approach is that people also have the necessary information that is relevant to them in defining their personal situations, both with reference to the problematic aspects, as well as to the potential solutions. This knowledge may be useful in prefiguring a patient's future. The social worker sees an opportunity when observing a client's resourcefulness and perseverance in managing a difficult situation. The strengths approach enables social workers to encourage clients to define and attribute meaning to their situations. Simply listening to and accepting the client's opinion is a recognition of the client's capacity and the quantity of internal knowledge of the situation (Weick, 1983; Weick & Pope, 1988, sources cited by Early, GlenMaye).

Consumers of social work services arrive in this situation because they are oppressed by society or abused by various people. According to Gutierrez, (1990 source cited by Early, GlenMaye) "Remembering the strengths necessary to struggle against oppression offers clues about client capabilities that the social worker should validate and build on. For example, when working with women who have been battered, social workers should identify the internal and external resources used to survive violence. A strength is whatever enabled a woman to begin to take control of her life."

Furthermore, another very important aspect of the strengths perspective is that human beings are considered to be very resilient, which means that human beings often survive and thrive despite all odds. As a consequence, increased confidence results in increased resilience (Anthony & Cohler, 1987; Garmezy, 1993; Haggerty, Sherrod, Garmezy, & Rutter, 1994 sources cited by Early, GlenMaye).

The discussion about the influence of the psychoanalyst and the strengths perspective applied to social work proves that the role of ethics in performing social activity is crucial. Since the patient is very vulnerable and easy to influence, the lack of morality would have extremely serious consequences on the future life of the person subjected to treatment. The importance of moral conduct cannot be sufficiently emphasized in this case.

4- How theory applies to working with individuals, families and/or small groups

Working with individuals is slightly different than working with families or other small groups. Introduction of psychoanalysis in social work poses a new set of methodological and ethical problems. According to Germain, (1970) and Petr & Spano, (1990) "The adoption of Freudian ideas in social casework, psychoanalytic techniques, and such movements as mental hygiene and child guidance define the era of diagnostic social casework."

The most appropriate field of work for psychoanalysis is the one where problems within the psyche are determine to have manifestations in behavior and relationships. In child guidance clinics, working with parents concentrates on change through education, while later in the process, mothers' personality difficulties became the object of the focus. (Hartman & Laird, 1983, cited by Early., GlenMaye,).

The Psychosocial Approach, begun in the 1930s, was, according to Hollis (1970) "a continuation of the Freudian emphasis on individual functioning and on the necessity of diagnostically oriented assessment of deficits in the individual and in the environment." McBroom, (1970) stated that "The concern of this approach shifted from individual neurosis to character disorders, and more recently, to "multiproblem" families." Hollis continues to argue that "what has remained consistent in this approach is an intervention based on "understanding of each part of the personal and social systems involved in the client's trouble" (Hollis, 1970, p. 72, cited by Early, GlenMaye,).

The problem-solving approach had a different perspective on problems, which were considered a normal part of the human condition. The normalization of problems was performed by the 1970's Perlman thesis of "living is a problem-solving process." Problem-solving capacities were preferred by the approach, in the detriment of psychological change. Focusing on deficits continued, supported by the assumption that the inability to deal with problems was caused by one or more of three deficits. As Perlman has put it: "the motivation to work on the problem in appropriate ways; the capacity to work on the problem in appropriate ways; the opportunity, whether of ways or means, to meet or mitigate the problem"

Bartlett and other practitioners have tried in the 1950's to place an emphasis on developing a theory of family diagnosis. Unfortunately, the available methods, which involved individually oriented psychoanalytic concepts, were more of a limitation to the effort than a genuine help. In the process of diagnosing and treating families, concepts such as ego psychology were used (Germain, 1970).

Individually oriented concepts couldn't explain in a satisfactory way the functioning of a family, so social workers began to look for support on the systems theory Germain, 1968; Hearn, 1958, 1969; Meyer, 1970, cited by Early, GlenMaye), which provided a framework for analyzing and organizing data about families.

Systems were used to conceptualize "the person-family constellation in its life space and for focusing on the transactions between the person or family and the social environment" Hartman and Laird (1983). Other researchers, (Wells & Biegel, 1992) used practice models in which the family and its dysfunctional transactions are the center of attention, ranging from family therapy to family preservation programs. Hartman and Laird (1983) have also presented a family-centered social work, who is still maintaining the emphasis on problems as "lacks or deficits in the environment, as dysfunctional transactions between systems, as adaptive strategies, or as results of interrupted growth and development rather than as disease processes located within the individual"

5- Discuss impact of racial, ethnic or soci0-cultural issues of the application of psychoanalytic theory.

Since psychiatry is seen as a method of social control, and racism as a form of oppression which influences society at large, the public's imagination has made a connection between racism and psychiatry. Racism is often blamed for being a 'mediating factor' in cases of 'psychiatric misdiagnosis' and 'mismanagement'. Misdiagnosis refers to both underdiagnosis and overdiagnosis and accounts for the lack of action and failure to prescribe adequate treatments due to an erroneous diagnostic. Usually, in the case of some ethnic groups, people do not seek help for very long periods of time.

Racism is not a new phenomenon, but the term creates confusion, as it is applied very often and without caution to all sorts of situations. It is not clear which exactly are the processes that are taking place, the degree to which the processes are institutionalized or individual and how much are the individuals aware of the impact of their actions.

The psychoanalytic theories developed by Freud in Vienna in the nineteenth century are currently universally accepted and adopted, although there is a close connection to the culture of that specific period. Despite the recommendations of some authors (Chess et al. 1953, cited by Bhugra, Dinesh, Bhui, Kamaldeep), some analysts have adapted it without modifications for the study of other cultures and groups. These authors suggest that, "unless the social milieu in which the patient functions is understood and given adequate consideration, significant errors in psychiatric management and prognostic factors will occur." Therefore, Psychoanalysis has been branded as racist.

Bughra and Bhui point out, in their 1997 study that "Patients from ethnic minorities are frequently not offered counseling or psychotherapy on the premise that such individuals are not psychologically sophisticated or psychologically minded."

The two authors find another problem here: "Therein lies another fallacy because psychological concepts practiced and taught in the West are very culture-bound and the indigenous psychologies and psychological interventions are ignored. There is plenty of clinical evidence to suggest that in spite of language barriers, group therapy works in ethnic minorities and with appropriate modifications family therapy can be undertaken successfully"

The needs of the clinical management of ethnic minorities' health care system stays in the social, economic, political and health care context and in the application of the standard psychiatric criteria for prognosis, diagnosis, and treatment. The results of psychological testing related issues are also decisively influenced by cultural and environmental factors. Another very different thing across the world is the concept of underlying personality, which varies wildly across cultures; personality in itself is not a static phenomenon and has to be assessed accordingly, in order to obtain proper results.

6- Discuss evaluative research of the effectiveness of the theory to a specific client population; ex. children, gay/lesbians.

Lesbian and gay liberation politics have as a goal a firm response to the pathologizing of homosexuality within classical psychoanalysis and its various revisions (ego psychology, self-psychology, object relations, and most recently, relational psychoanalysis). Despite the fact that Freud had proposed contradictory perspectives to homosexuality, his negative ideas on the subject have influenced not only psychoanalysis but also all mental health work in psychology, psychiatry, and, as a consequence, social work. Freud's influence has been so overwhelming that even feminist practitioners who do not support Freud's ideas are in constant debate with his concepts.