Freudian Psychotherapy: Technique

   (1893–1930s).

   The "cathartic method" of Breuer and Freud (1893, 1895). In an article for the Neurological Central Journal (Neurologisches Centralblatt), Freud and Josef Breuer (1842–1925) reported the case of a young female patient with hysterical symptoms whom Breuer in the early 1880s had on successive occasions hypnotized, persuading her to shed her symptoms each time by coaxing her to recall her psychic condition at the origin of the symptom, thus achieving a "catharsis." As the two authors wrote in their 1893 "Preliminary Communication" (in James Strachey’s translation), "The injured person’s reaction to the trauma only exercises a completely ‘cathartic’ effect if it is an adequate reaction—as, for instance, revenge. But language serves as a substitute for action; by its help, an affect can be ‘abreacted’ almost as effectively" (p. 59 of Penguin edition). In 1895, Breuer and Freud published Studies in Hysteria (Studien über Hysterie); in his part of the book, Breuer reported this case more extensively, identifying the patient with the pseudonym "Anna O." (As English psychiatrist and psychoanalyst Ernest Jones revealed years later in his biography of Freud, her real name was Bertha Pappenheim [1859–1936].)

   In his own practice, Freud began using the cathartic method, with or without hypnosis, then gradually going over to free association as a way of eliciting buried memories. In the conclusion of Studies in Hysteria, Freud said, "I have often in my own mind compared cathartic psychotherapy with surgical intervention. I have described my treatments as psychotherapeutic operations; and I have brought out their analogy with the opening up of a cavity filled with pus, the scraping out of a carious region, etc." (p. 392). Yet, it turns out that not all the details that Breuer reported of the Anna O. case were historically correct, and interested readers may wish to review her real tale, which the German medical historian Albrecht Hirschmüller has rescued from the records of the Swiss sanatorium "Schloss Bellevue" in Kreuzlingen, where she was subsequently admitted after Breuer’s treatment (see his biography of Josef Breuer, published in 1978).

   Freud’s psychoanalytic method (1904 and after). (See also ID.) Although Freud’s techniques evolved steadily from the time of the cathartic therapy (early 1890s) onward—and may be gleaned from his various case studies, only around 1904 does he start to explain the technique of psychoanalysis. In a paper he published in a volume that Munich psychiatrist Leopold Löwenfeld (1847–1924) edited, on Psychic Compulsive States (Psychische Zwangserscheinungen), Freud laid out what he called "Freud’s Psychoanalytic Method" ("die Freudsche Psychoanalytische Methode"), explaining that he places his patients in a comfortable recumbent position on a sofa, with Freud seated on a chair behind them. Speaking of himself in the third person, Freud continued, "He reminds them, before they get into a detailed recounting of their case history, to say out loud everything that runs through their head in this connection, even if they believe it to be unimportant or irrelevant, or that it is nonsense. With special emphasis, however, they are called upon not to exclude any thought or recollection from the account on the grounds that this information could be shameful or embarrassing." The analyst then sees what has been left out of the account, or repressed, in an act of resistance. The significance of the resistance must then be interpreted (Deutung), the details of which Freud said he was not yet ready to make public (Gesammelte Werke, V, pp. 5–7).

   According to psychoanalysis historian Reuben Fine, Freud’s psychoanalytic technique evolved through four stages: (1) making the unconscious conscious (1886–1905), (2) working through transference and resistance (1905–1914), (3) plumbing the architecture of the psyche, in terms of ego and id (1915–1923), and (4) the function of analysis as creating a proper setting for ego functioning (1923–1939) (see Fine, History of Psychoanalysis, p. 499).

   Stekel’s "brief" psychoanalytic technique (1919).* One innovative idea of Vienna psychoanalyst and heretic Wilhelm Stekel (1868–1940), over which the offi-cial psychoanalytic movement has passed largely in silence, is Stekel’s notion of ending psychoanalytic treatments successfully within 3 to 4 months. He adumbrated this view in an article in Today’s Therapeutics (Therapie der Gegenwart) in 1919, saying "Anxiety neuroses have a good prognosis and are curable in four to six weeks" (p. 339). Then in his 1938 book about technique (Technik der analytischen Psychotherapie), Stekel returned to the theme more fully: "Many years ago I called attention to the fact that one can achieve splendid results in a short time (in 2–3 months). Patients who came to me from abroad and were unable to remain in Vienna more than 6 to 8 weeks were freed of their complaints and were made well again in a personal and social context. As counterexamples I knew of many interesting foreigners who had been in daily analysis over a year and even five years (!) without improving an iota." Referring to his brief, interventionist technique as the "active method," he said the analyst must follow his intuition in quizzing the patient (otherwise forbidden in classical psychoanalysis), because: "The patient is an actor, who plays a part both to himself and to us and believes that he is getting the better of us. Of course Freud believes in the unconscious. I no longer believe in the unconscious. Thirty years of experience have proven to me the contrary" (pp. 7–9; exclamation in original). Ferenczi’s "active" psychoanalytic technique (from 1920). In a speech at the Sixth International Congress of Psycho-Analysis at The Hague in 1920, Hungarian analyst Sandor Ferenczi (1873–1933), a family doctor in Budapest who brought psychoanalysis to Hungary and was one of Freud’s closest co-workers, described "active therapy," a technique he said he was "further" characterizing, thus intimating that it was Freud who had first come up with it. But in contrast to Freud’s "passive" technique, Ferenczi’s "active" methods involved giving patients all kinds of interactions: "I soon had the opportunity to apportion to a patient tasks that consisted in her renunciation of certain hitherto pleasurable activities (onanistic stimulation of the genitals . . . ). The result was that new memories became accessible and the progress of the analysis was visibly accelerated" (Ferenczi, Further Contributions, English translation, 1927, p. 201). In fact, Ferenczi was full of prompts for his patients, giving them orders—later "suggestions"—and prohibitions, encouraging them to vent their negative feelings * The beginning of brief psychotherapy is usually associated with psychoanalysts Otto Rank (1884–1939) and Sandor Ferenczi (see below), who in their 1924 book, The Development of Psychoanalysis (Entwicklungsziele der Psychoanalyse), argued that analyses could be shortened if the analyst renounced the goal of illuminating every last aspect of the patient’s personality structure: "It was a fateful error to believe that no one can be completely analyzed who has not been theoretically enlightened about all the details of one’s own abnormalities" (p. 50). Yet, Stekel clearly preceded them. toward their therapists, even kissing some of them. The idea was, in the words of Ferenczi’s young colleague Sandor Lorand (1893–1987), "to request the patient—in addition to using free association—to act or behave in a certain way, in the hope of increasing tension, thereby mobilizing unconscious material." Ferenczi had the view that some very intractable patients required "love," in order for them to restore contact with their psychic condition before the trauma occurred (Lorand, in Alexander, ed., Psychoanalytic Pioneers, pp. 20, 23).

   Kohut’s "self psychology" (1971). Heinz Kohut’s self-psychology was one of the three streams into which classic Freudian psychoanalysis broke (the other two being ego psychology, which is a continuation of the classic tradition, and object relations theory, which is associated with the United Kingdom and rival subcamps having as their quarrelsome historic leaders Melanie Klein, Anna Freud, and Donald Woods "D. W." Winnicott (1897–1971). Self-psychology made a large impact in the United States in the 1970s and 1980s after the publication of Kohut’s book, The Analysis of the Self (1971).

   Heinz Kohut (1913–1981), a Vienna-born physician who had fled Austria to come to the United States in 1941 (where he resumed his medical career as a resident in neurology in Chicago), believed that classic psychoanalysis did not work for the kinds of help that patients were increasingly seeking. Rather than requesting relief for classical psychoneurotic symptoms, U.S. patients were having problems with relationships or experiencing a sense of meaningless. Kohut labeled this new pattern of complaints with Freud’s term "narcissism" (see Narcissism; Personality Disorders: DSMIII [1980]) and recommended an empathic kind of psychotherapy to fill the patient’s "self." Kohut wrote in The Analysis of the Self of these narcissistic personalities: "The spontaneous establishment of one of the stable narcissistic transferences [transference permits depth psychotherapy to take place] is the best and most reliable diagnostic sign which differentiates these patients from psychotic or borderline cases, on the onehand, and from ordinary transference neuroses, on the other" (p. 4). As for symptoms, Kohut said, "The patient will describe subtly experienced, yet pervasive feelings of emptiness and depression. . . . The patient will attempt to let the analyst know that . . . he is not fully real, or at least that his emotions are dulled; and he may add that he is doing his work without zest, that he seeks routines to carry him along since he appears to be lacking in initiative" (p. 16). Addressing these kinds of complaints in urban post-1970s America procured for Kohut a large following.

   Sifneos’s "short-term psychotherapy" (1972). In his role as director of the Psychiatry Clinic of the Massachusetts General Hospital from 1954 to 1968, Peter E. Sifneos (1920–) developed a short-term psychotherapy technique based on the principle of provoking anxiety through challenging questions rather than assuaging it. In his book Short-Term Psychotherapy and Emotional Crisis (1972), Sifneos called his technique "similar in theory" to long-term psychoanalytic psychotherapy but focused on solving the patient’s main emotional problem. The crisis-intervention phase lasted up to 2 months and the "short-term anxiety provoking" part 2 to 12 months. Sifneos added, "Psychoanalysis, of course is anxiety-provoking psychotherapy of long-term duration" (p. 71).