Despite controversy, psychoanalysis rose in popularity around the world during the 1920s.

11 What can psychoanalysis contribute to pain psychology?

Sigmund Freud created psychoanalysis from his work as a neurologist with patients who had “pain without lesion”—a concern of 19th century physicians. Psychoanalytic theory has much to offer pain psychology. Unconscious factors in emotional life—such as repressed memories or traumas, unresolved conflicts, unprocessed emotions, and ineffective mechanisms of defense against negative emotions—may all influence pain perception. The patient's relational style may impact their interactions with medical practitioners. Attachment in early life influences emotional regulation and management of distress. Mental schemas are used to manage distress; these develop from interactions with caregivers. These “attachment styles” may determine the response to stress. Research has substantiated that people with insecure attachment styles may influence pain outcomes due to a more realistic assessment of threat and a more positive outlook.

Introduction

Psychoanalysis is a theoretical framework of human development, psychological functioning, psychopathology, and change processes, as well as a distinctive model of psychotherapy. Psychoanalysis was the first modern Western system of psychotherapy, and most other forms of therapy evolved out of psychoanalysis were strongly influenced by it, or developed partially in reaction to it. Over the years a variety of different psychoanalytic traditions have been developed by different theorists and researchers around the world. Examples include: classical psychoanalysis, ego psychology, Jungian psychoanalysis, Kleinian theory, object relations theory, self psychology, interpersonal psychoanalysis, modern conflict theory, Lacanian psychoanalysis, and relational psychoanalysis.

Despite the lack of a single unified perspective, certain central principles cut across different psychoanalytic theories. These include: (1) the assumption that that all human beings are partly motivated by unconscious fantasies, wishes, or tacit knowledge that is outside of awareness, (2) a focus on facilitating awareness of unconscious motivations in order to increase choice, (3) an emphasis on exploring how we avoid painful or threatening feelings, thoughts and fantasies, (4) an assumption that we are ambivalent about changing and that it is important to explore this ambivalence, (5) an emphasis on using the therapeutic relationship as an arena for exploring clients’ conscious and unconscious self-defeating psychological processes and behaviors, (6) an emphasis on using the therapeutic relationship as a central vehicle of change, and (7) an emphasis on helping clients to understand how their own construction of their past and present plays a role in perpetuating their self-defeating patterns (Safran, 2012).

The term psychoanalysis was originated by Sigmund Freud (1856–1939), a Viennese neurologist, who developed the discipline together with a number of colleagues (e.g., Wilhelm Stekel, Paul Federn, Max Etington, Alfred Adler, Hans Sachs, Otto Rank, Karl Abraham, Carl Jung, Sandor Ferenczi, Ernest Jones). The emergence of this discipline was influenced by developments taking place at the time in neurology, psychiatry, psychology, philosophy, and the social and natural sciences. Although psychoanalysis began with Freud’s writing and lectures and the work of a small group of colleagues primarily in Vienna, by the time of Freud’s death in 1939 it began to grow into an international movement with important centers in Vienna, Zurich, Berlin, Budapest, Italy, France, England, the United States, and Latin America, which each contributed its own unique influence to the development of different schools and theories of psychoanalysis (Makari, 2008). Different schools interpret Freud’s writing differently and debate various premises and aspects of Freud’s theory and technical recommendations for the clinical practice of psychoanalysis.

Multiple Choice Answers

Q1

The answer is: Anton Mesmer.

The origin of medical hypnosis is generally attributed to Anton Mesmer, a Jesuit-trained eighteenth-century physician, who believed that health was determined by a proper balance of a universally present, invisible magnetic fluid. Mesmer's early method involved application of magnets. He was an important medical figure at the Austrian court, but he fell into discredit when a scandal occurred around his care of Maria Paradise, a young harpsichordist whose blindness appears to have been a form of conversion disorder.

Mesmer re-established his practice in Paris and employed a device reminiscent of the Leyden jar, a source of significant popular interest in the Age of Enlightenment. His patients sat around a water-containing iron trough-like apparatus (bacquet) with a protruding iron rod. He was a colorful figure who accompanied his invocation for restored health with the passage of a wand; there was no physical contact with his patients. Susceptible individuals convulsed and were pronounced cured. An enthusiastic public greeted Mesmer's practice and theory of “animal magnetism.” However, medical colleagues were less impressed.

The French Academy of Science established a committee, led by Benjamin Franklin, the American Ambassador to France, who was an expert in electricity. The committee found no validation for Mesmer's magnetic theories, but determined that the effects were due to the subjects' “imagination.”

James Esdaile, a nineteenth-century Scottish physician, was the first to take advantage of the somnambulistic state induced by Mesmerism to relieve surgical pain. Esdaile served as a military officer in the British East India Company, and took care of primarily Indian patients in and around Calcutta between 1845 and 1851. Over this period, Esdaile performed more than 3,000 operations (including hundreds of major surgeries) using only Mesmerism as an anesthetic, with only a fraction of the complications and deaths that were commonplace at the time. Many of these operations were to remove scrotal tumors (scrotal hydroceles), which were endemic in India at the time, and which in extreme cases swelled to a weight greater than the rest of his body. Before Esdaile's use of Mesmeric anesthesia, surgery to remove these tumors usually resulted in death, due to shock from massive blood loss during the operation.

Early in the nineteenth century some surgeons advocated the use of this new procedure for pain reduction in the operating theater. James Braid, a British surgeon, called it “hypnosis” after the Greek root for sleep. Some questioned its apparent utility, and thought it a humbug.

Although Sigmund Freud (the father of psychoanalysis) was a skilled hypnotist, he came to believe that it had an unwanted impact on transference and it was therefore incompatible with his psychoanalytic method. Instead, Freud substituted his method of free association.

The answer is: Milton Erickson.

Eriksonian hypnosis, named for its founder, Milton Erikson, is a counterpoint to Freud's earlier position. Erikson advocated strategic interactions with his patients that employed use of metaphor and indirect methods of behavior-shaping. While hypnotizability is generally considered to be an individual trait, Erikson believed that the efficacy of hypnotherapy depended on the skill of the therapist.

A prominent internist, Hippolyte Bernheim, studied hypnosis at a French school at Nancy. He worked with a country doctor known as “Pere Liebeault” for hispro bono work with patients who agreed to undergo hypnosis for therapeutic purposes. The Nancy School found hypnosis to be a normal phenomenon that operated through suggestion.

Martin Orne's work at the University of Pennsylvania identified the demand characteristics (that were based on a hierarchical relationship) of interaction between the hypnotist and the subject. He used sham hypnosis as an effective research tool. Orne also addressed the memory distortion that can occur with hypnosis and exposed its lack of validity for courtroom procedures, and he defined “trance logic” as a willing suspension of belief that highly hypnotizable subjects readily experience.

David Spiegel has pointed to absorption, dissociation, and automaticity as core components of the hypnotic experience. Absorption has been found to be the only personality trait related to an individual's ability to experience hypnosis.

Joseph Wolpe applied hypnosis or progressive muscle relaxation to facilitate systematic desensitization.

The answer is: Hay fever.

Review of multiple randomized clinical trials shows that several conditions (e.g., cancer pain, pain of labor and childbirth, pain related to medical procedures, symptoms of irritable bowel syndrome, postoperative wound healing, and obesity) have been improved by use of hypnosis.

No evidence of efficacy (from controlled trials) has been found for use of hypnosis in schizophrenia, sufferers of hay fever, and delayed-type hypersensitivity responses.

The answer is: Paranoia.

Contraindications to the use of hypnosis are limited to its use among paranoid individuals and it its coercive application.

Rather than serving as a contraindication to its use, hypnosis may improve the pain of childbirth and facilitate weight loss in obesity. There is also some evidence that it may improve symptoms of conversion disorder, facilitate smoking cessation, and control tinnitus.

The answer is: True.

Reliable measurement of hypnotic susceptibility is available with several scales (including the Stanford Scales and Harvard Group Scales of Hypnotizability).

Across scales, approximately 10% to 15% of subjects fall into the “high hypnotizability” range, another 15% to 20% fall in the “low hypnotizability” range, and the remainder falls in an intermediate range.

Moderate levels of hypnotizability are important for clinical efficacy, although the level of hypnotic responsiveness does not ensure therapeutic success.

The Tellegen Scale of Absorption also correlates with hypnotic responsiveness. Absorption refers to a process of concentration and a narrowing of attention. Clinical observations of absorption (for example, in competitive sports and other forms of performance) may be a clue to a patient's hypnotizability.

Psychoanalysis is linked with the name and owes its systematic elaboration to Sigmund Freud (1856–1939). Freud's biography and the interpretation of psychoanalysis constitutes an important chapter in twentieth century cultural and intellectual history, both as a body of theory and as cultural practice. An ongoing attempt to determine the meaning of Freud and psychoanalysis has led to the publication of hundreds of volumes, and the historiography of psychoanalysis has found its own place within the history of science. Each culture has absorbed Freud and psychoanalysis differently, but a general history of psychoanalysis as a single science can be catalogued in three ways: (a) as a history of psychoanalytic theories from Freud to the present; (b) as a history of Freud's biography, the psychoanalytic movement, and its institutions and practices; and (c) as a self-reflection on the historiography of psychoanalysis itself, and problems of methodology. In the history of psychoanalysis, studies in the area of Freud-biography and the pre- and early history of psychoanalysis dominate. However, since the late 1960s, a coherent picture of Freud and the psychoanalytic movement has undergone a profound change depending on the authors' background either inside or outside of institutional psychoanalysis.

Psychoanalysis refers to the psychological theory and clinical practice developed by Sigmund Freud in the early twentieth century and to its later developments. It is generally agreed that psychoanalysis is distinguished by its commitment to the concept of the dynamic unconscious. Psychoanalysis raises many theoretical questions, chiefly on account of its apparent commitment to both mechanistic, reductionist modes of psychological explanation, and a hermeneutical conception of explanation as a matter of grasping relations of meaning. The former has given rise to extensive consideration of psychoanalysis in the context of scientific methodology, where its claims to objectivity and well-foundedness are largely denied. More favorable views of psychoanalysis are associated with its reception as a hermeneutical discipline and construal as a theoretical extension of commonsense (‘folk’) psychology. The main developments in psychoanalysis after Freud may be divided into those that attempt to synthesize psychoanalysis with other bodies of theory in the human sciences, such as Marxism and feminist theory, and those that aim to carry forward Freud's own theories of individual mental functioning. Prominent in the latter category are the theories of Alfred Adler, Carl Jung, Melanie Klein and the British school of object-relations, and Jacques Lacan.

1.01.9.2 Psychoanalysis

Psychoanalysis virtually swamped the field of psychotherapy early in the century, relying on the treatment principles of free association and interpretation by the analyst. Freud's writings attracted many disciples. Also, outpatients were willing to pay for this kind of treatment for periods of months and years, if so advised. Psychoanalysis soon began organizing itself in a formal way. The first international psychoanalytic congress was held in Salzburg in 1908. Freud and Jung were invited to the United States in 1909 to speak at Clark University. Psychoanalysis also soon began a process of fission, with Alfred Adler (1870–1937) breaking away in 1911. Then in 1913 Carl Jung (1875–1961) left the fold. In that same year, Freud and certain colleagues set up a small group called “the Committee” to maintain more oversight of psychoanalytic orthodoxy. Interestingly, each of its offshoots seemed to follow Freud's pattern of elaborating a theory of psychopathology and treatment and establishing formal organizations that its adherents could join.

Freud thought of psychoanalysis as an independent field, separate from psychiatry and medicine, and was willing to train analysts (including psychologists) who lacked a medical background. The American Psychoanalytic Association, founded in 1911, had ideas different from Freud's about the relation of psychoanalysis to medical practice and after 1938 for 50 years restricted its accredited institutes to offering training to medical candidates only. In 1926, on the other side of the Atlantic, psychologist Theodore Reik had been tried for practicing medicine without a license, that is, for doing psychoanalysis. Reik was acquitted. In fact, Freud himself came to Reik's defense (S. Freud, 1927). In 1985 Bryant Welch (a psychologist-attorney) and three psychologist colleagues filed a lawsuit against the American Psychoanalytic Association for this practice as a violation of federal antitrust law. In 1988 the organization settled the suit out of court and began allowing social workers and psychologists to become trainees. According to Shorter (1997, p. 310), the number of non-medical candidates in training soon rose to above 20%.

In France, psychoanalysis emerged as a highly influential approach, but a number of years after it had done so in the United States (Roudinesco, 1990). Psychoanalysis in France began with the work of Marie Bonaparte and her colleagues in the 1920s (Bertin, 1982). This included the founding of an institute and a professional journal as well as the translation of some of Freud's writings into French. Psychiatrist and psychoanalyst Jacques Lacan (1901–1981) was active on the French psychoanalytic scene beginning in the 1930s but began his influential seminars in Paris only in 1953. The legal issue of lay vs. medical analysis also arose there. After the student disturbances of 1968, psychoanalysis assumed a greater representation in French university curricula. In 1973 Lacan published a book on what he considered the four fundamental concepts of psychoanalysis. Lacan's “deconstructionist” approach was popularized in literary circles by Jacques Derrida. Even today, if one examines the shelves of a bookstore in Paris, the section on psychoanalysis is highly visible, but there may be no sections labeled psychology or psychiatry.

The influence of psychoanalysis in Britain and the United States had been evident well before that in France. The Rockefeller Foundation provided some funding for the Chicago Psychoanalytic Institute in 1925. Franz Alexander (1891–1964) was appointed professor of psychoanalysis at the University of Chicago in 1931, the first such academic recognition for the field (Mora, 1994). The role of psychoanalysis in the United States and Britain increased during the 1930s, with the immigration of many analysts from continental Europe fleeing Hitler. As the American interest in psychoanalysis cooled somewhat in the 1970s, Roy Schafer (1976) and others began to reconsider whether psychoanalysis ought to model itself after the natural sciences. Perhaps, Schafer suggested, it would be more appropriate to consider psychoanalysis to be part of the humanities. Its use of hermeneutic approaches in interpreting patients' utterances were seen as similar to those of literary scholars in interpreting poems and fictional narratives. The philosopher of science Adolph Grunbaum (1984, 1993), an outsider to psychoanalysis, criticized its use of a patient's subsequent behavior as a way of confirming the correctness of psychoanalytic interpretations. Other criticisms came from insiders, such as psychoanalyst-historian J. M. Masson (1984). Nevertheless, psychoanalysis continues as a viable profession and as an influence on scholars over much of the world. Its influence continues to spread in Latin America and elsewhere during the late twentieth century.

Freud in Context

Psychoanalysis is one of those rare intellectual achievements that had the effect of radically transforming human self-understanding. Indeed, Freudian notions have so thoroughly permeated human culture that the jargon (if not the substance) of psychoanalysis is accessible to even the most untutored observers of human behavior, so much so that the poet W.H. Auden could write that for us, Freud is not so much a person but rather a whole climate of opinion under whom we conduct our different lives. By Freud's own estimation, psychoanalysis effectively completed the intellectual revolution begun by Copernicus, and advanced by Darwin, a revolution that undermined human conceit regarding its putatively special and privileged position in the cosmos and in nature. While Copernicus displaced mankind's planet from the center of the universe and Darwin showed that no comfort can be taken in the idea that mankind is nonetheless above the forces of nature, Freud completed the assault on human pretense by showing that even human reason is not what it has been supposed, that human psychology is, in fact, besieged and driven by irrational, unconscious motivations.

Freud's discovery of a hidden psychic reality that is beyond the pale of sensible consciousness was thought (by Freud) to be an application of the same Newtonian dualism that accepted the distinction between human sensory abilities (percepts) and a hidden physical reality that could only be apprehended by mathematics and the armamentarium of physical science. The Newtonian scheme was invoked by psychoanalysis to advance an understanding of psychic life, an application that hinges on the distinction between conscious and unconscious mental life. Just as physics develops scientific techniques to apprehend a physical universe that is beyond human sensibility, so also psychoanalysis attempts to pierce hidden unconscious realities with its special clinical techniques. Psychoanalysis, then, according to Freud, is to be counted among the natural sciences; it is a specialized branch of medicine (with the caveat that medical training gives no necessary expertise in psychical affairs), with mental life being the object of inquiry.

Although psychoanalysis shocked conventional sensibilities, particularly with its claims regarding unconscious mental dynamics and infantile sexuality, it was grounded nonetheless in themes common to nineteenth century science. The Freudian theory of instincts seemed at home in a culture that was getting used to the ideas of Darwinian biology. Freud's use of spatial models to locate psychic structures was in keeping with the efforts in neurology to localize brain functions. And the mechanistic Freudian image of the psychological architecture as an apparatus for channeling instinctual drive energies was not out of step with the energy mechanics of nineteenth century physics. Yet, for all the trappings of scientific positivism that Freud wanted to claim for psychoanalysis, the Freudian project was met with considerable resistance, and the history of the psychoanalytic movement is a history of struggle for academic, clinical, and popular respectability, a respectability that is still not completely won.

Freud himself was at pains to recount this struggle in a number of histories, outlines, and encyclopedia articles. Although one aim was to popularize the new science of mental life, Freud was also keen to demarcate psychoanalysis from rival depth psychology (e.g., Jung, Adler) and to show that the controversial psychoanalytic claims were the result of careful scientific investigation of the positivist, natural science kind. He would claim, for example, that the hypothetical entities and forces of psychoanalysis were not different in kind from the hypothetical entities and forces claimed in the ostensibly harder, more respectable sciences. It will be of interest for our purposes to recount the early development of psychoanalysis to set the proper context for considering Freud's account of the tripartite personality. The structural notions of id, ego, and superego were rather late theoretical developments that can be understood properly only in the context of prior theoretical revisions – revisions that Freud would claim were forced upon psychoanalysis by evidentiary warrant.

Psychoanalysis is (a) a personality theory, and, more generally, a theory of psychological functioning that focuses particularly on unconscious mental processes; (b) a method for the investigation of psychological functions based on the exploration of free associations within a special therapeutic setting; and (c) a method for treatment of a broad spectrum of psychopathological conditions, including the symptomatic neuroses (anxiety states, characterological depression, obsessive compulsive disorder, conversion hysteria and dissociative hysterical pathology), sexual inhibitions and perversions (‘paraphilias’), and the personality disorders. Psychoanalysis has also been applied, mostly in modified versions, that is in psychoanalytic psychotherapies, to the treatment of severe personality disorders, psychosomatic conditions, and certain psychotic conditions, particularly a sub-group of patients with chronic schizophrenic illness.

I. Introduction

Psychoanalysis is a theory and a method for understanding the development and functions of human psychology, especially the emotions. Psychoanalysis is a theory of human emotional development based on observations and treatment for emotional illness. Psychoanalysis and psychoanalytic therapy are talking treatments in which a person's psychology is explored in order to help the person master emotional conflicts. These conflicts are manifested in mental symptoms, in troubled relationships with others, in work, in love inhibitions and disruptions, in unhappiness, and in poor self-esteem. Through a detailed description of what troubles a person, and all the associations this brings to mind, the elaborate complexity of how the person's mind functions is brought to consciousness.

Psychoanalysis is based on the concept of unconscious mental representations that are built up from childhood. These mental representations of self and others include intense and conflicted emotions. The conflicted emotions involve wishes, associated fears, and attitudes that organize compromises among them. These representations are influenced both by temperament and experience. The representations are linked by association mainly of affect. They are mediated by and encompass the various groups of mental functions. They can be made conscious in an affect-stimulating relationship and changed if they can then be consciously observed and thereby better synthesized in more adaptive ways. The psychoanalyst achieves this goal by becoming the focus of and then analyzing the patient's projections of mental representations and attitudes.

Mental representations and attitudes include conflicted emotions. Emotional conflicts involve simultaneous wishes and fears. An example is envious hatred of, and longing feelings of love for, the same person, or the same type of relationship. The compromise might be avoiding love and having unhappy, longing feelings. If a compromise of distant love is rigid and fixed, the patient's love life will be lonely, sad, and unrequited. Psychoanalysis, tries to understand the conflict and its defensive avoidance so thoroughly that the patient can understand and achieve a new and better compromise that involves an intimate relationship.

The idea that we are not aware of all our feelings, of all the conflicts in our feelings, of the ways we defend against them, and the ways we compromise those feelings in our minds and in our everyday lives, or the rules that organize those compromises, was first thoroughly researched and systematized by Sigmund Freud. He discovered the rules of organization of emotional life in the late 19th century when the physical sciences were beginning to discover the rules of organization of physical matter. Freud's initial training was in physical science and neurology and he brought that intellectual approach to his study of human psychology and the unconscious.

I. Description

Relational psychoanalysis is an intensive form of psychotherapy that places human relations at the center of motivation, psychopathology, and treatment. It is an alternative to classical Freudian psychoanalysis (including its modifications in psychoanalytic ego psychology). It considers relations to others, not drives, as the basic building blocks of mental life. From the relational perspective, individual experiences and the internal structures of the mind are viewed as deriving from and are transformations of relationships with significant others.

The term “relational psychoanalysis” is a relatively new coinage. It refers to a theoretical and clinical sensibility that integrates a variety of psychoanalytic theories that have evolved following the promulgation of Freud's seminal ideas. Thus, it is a contemporary eclectic approach that has beenbeen in a process of growth and development in the United States for the last 20 years. This new perspective includes recent developments within, and cuts across, U.S. interpersonal psychoanalysis, the British school of object relations, self psychology, and currents within contemporary Freudian theory. It is concerned with the intrapsychic as well as the interpersonal, but the intrapsychic is seen as constituted by the internalization of interpersonal experiences. Although these internalized interpersonal experiences may be biologically mediated, relational psychoanalysis is primarily concerned with the psychological determinants of experience.

There is considerable variation in the practice of relational psychoanalysis, but all relational analysts share a sensibility in which the therapeutic relationship plays a superordinate role in the treatment. Thus, the analyst's subjectivity and personal involvement, including partially blinding entanglements, are given serious consideration. Gender, class, race, culture, and language are additional factors of great significance to relational analysts.