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Chapter: Essentials of Psychiatry: Psychoanalytic Theories

Psychoanalytic Theories: Development and Major Concepts

Freud’s Contributions, Post-freudian Ego Psychology.

Development and Major Concepts


Freud’s Contributions




Freud’s study (1900, 1901) of dreams during his self-analysis and in his work with patients resulted in an elaborate understanding of the workings of the mind. The analysis of dreams continues to hold a prominent position in psychoanalytic practice. Dreams give expression to unconscious wishes in disguised form and generally represent their fulfillment or gratification. Analysis of dreams can provide conscious access to unconscious drives, wishes, fantasies and associated repressed infantile memories, providing what Freud called the “royal road to the unconscious”.


The dream that is remembered on awakening is referred to as the manifest dream. Its component elements include sensory stim-uli occurring during sleep, the day residue and the latent dream content. The day residue consists of experiences of events of the preceding day or days, often associated in the mind with uncon-scious wishes. The latent dream content is the set of unconscious infantile urges, wishes, and fantasies that seek gratification during the dreaming state of blocked motor discharge and regression.


Freud hypothesized a dream censor whose function is to keep the unconscious latent content from conscious awareness, thereby preventing the emergence of anxiety and awakening from sleep. The surreal and fantastic quality of the remembered manifest dream is a reflection of the influence of dream work and primary process unconscious mentation (Table 18.1): depic-tion of immediate gratifications, absence of the rules of logic of conscious thought, merging of past and present, absence of nega-tives, loss of distinction between opposites and representation of a whole by a part. The activity of the dream work involves a set of mental mechanisms designed to disguise and distort the latent content in keeping with the function of the dream censor



In psychoanalytic treatment, the analysis of dreams attempts to take this process backward, starting with the patient’s narration of the dream and then observing the patient’s associa-tions to the manifest elements, with the goal of obtaining insight into the dreamer’s unconscious wishes, memories and infantile fantasies, and processes of defense.


Childhood Sexuality


In his analyses of adult patients and observations of children, Freud (1905) became convinced of the influence of early sexual fantasies on the formation of neurotic symptoms and of the univer-sality of sexual wishes throughout life including early childhood. The term sexuality is used in this context to refer not exclusively to adult genital sexuality but to a variety of body stimulations that are pleasurable and sensually gratifying. He postulated a devel-opmental sequence of body zones that become primary foci of erotic sensations and mental organization (Table 18.2): oral, anal (including perianal and urethral) and genital (phallic). During de-velopment, there is a more or less orderly progression from one zone to the next, with pleasure being derived from sucking, biting, tasting, touching, looking, smelling, filling, emptying, penetrating and being penetrated. In the neuroses, the repressed component instincts become an unconscious source of symptom formation.



Fixation (Table 18.3) at a particular phase of development may occur if there is insufficient mastery of issues pertinent to that phase. Fixations result in continued manifestations of phase specific issues in a person’s behavior, influencing later person-ality adjustment (e.g., the anal organization of the obsessional character). Regression (Table 18.3), a return to a less mature level

of mental organization, may occur in the context of stressors or conflict that overtaxes the adaptive capacities of an individual.


The first of the phases described by Freud is the oral phase (Table 18.4), which encompasses approximately the first 18 months of life. During this phase, the mouth, lips and tongue are the primary sources of sensual gratification. The activities of sucking, swallowing, mouthing and biting, as well as the experi-ence of being held during feeding, form a cognitive template for the organization of fantasy and relatedness to others. The infant at this stage is dependent on mother for nurturance, protection and sustenance. A favorable outcome of this stage is the estab-lishment of a capacity to feel trust and safety in a dependent


relationship, a sureness that needs will be recognized and grati-fied, and a minimum of conflict about aggressive wishes oc-curring during moments of frustration. Excessive neglect or deprivation during this period may result in adult feelings of interpersonal insecurity, mistrust, envy, depression, excessive dependency, anticipation of rejection by others and proneness to moments of diffuse rage.


The anal phase (see Table 18.4) emerges with the develop-ment of increasing neuromuscular control of the anal and ure-thral sphincters and takes place from about 18 months to 3 years. Fantasy organizes around anal pleasure and anal functions such as withholding, expelling and controlling. Because of the child’s increased motor skills, language development and emerging autonomy, she or he is expected to take more of an active part in self-care activities, including using the toilet. Related to toi-leting, power struggles may ensue around the child’s soiling or withholding. Anger is felt toward those in control of this educa-tive process, but the child also wishes to please them. The child in the anal phase experiences considerable ambivalence around expelling versus retaining (giving versus keeping), obedience and submission versus defiance and protest, and cleanliness and orderliness versus messiness. Fixation at this stage results in a personality organized around anal erotism and its associated conflicts, characterized by wishes to dominate and control peo-ple or life situations, rigidity, defiance and anger toward author-ity, neatness, orderliness, messiness, parsimony, frugality and obstinacy.


The phallic or phallic–oedipal or genital phase (see Table 18.4) occurs from the ages of 3 to about 5 or 6 years. At the onset of this period, sensual pleasure has become most highly focused around the genitals, and masturbatory sensations more closely resemble the usual sense of the word sexual. The child at this time has become even more autonomous and has more so-phisticated motor and language skills, conceptual capabilities and elaborate fantasies. The child is better able to recognize feelings of love, hate, jealousy and fear; has a more distinct recognition of the anatomical difference between the sexes; and appreciates that the parents have an intimate sexual relationship from which the child is excluded. Thinking about relatedness to others shifts from the largely dyadic (mother–child) quality of the prephallic phases to an appreciation of relational triangles.


Freud recognized in his patients’ associations that there were regularly occurring incestuous fantasies and wishes toward the parent of the opposite sex that were involved in the forma-tion of neurotic difficulties. He termed this phenomenon the Oedipus complex, in reference to the story of Oedipus, who unknowingly killed his father and married his mother. In the midst of the Oedipus complex, the child wishes to possess exclu-sively the parent of the opposite sex and to eliminate the parent of the same sex. The jealousy and murderous rage felt toward the same-sex parent are accompanied by fears of retaliation and physical harm. Because these fantasies are associatively linked to pleasurable genital sensations, the child has specific uncon-scious fears of being castrated, which Freud referred to as the castration complex. The oedipal phase proceeds differently in boys and girls.


Successful passage through the phallic phase includes resolution of the Oedipus complex and repression of oedipal fan-tasies. The child internalizes the parental prohibitions and moral values and demonstrates a greater capacity to channel instinctual energies into constructive activities. Excessive conflict or trau-matization during this phase may lead to a personality organized around oedipal fantasies and conflicts or a proneness defensively to regress to anal or oral organization.


During the latency phase (see Table 18.4), from age 6 years to puberty, play and learning take a prominent position in the child’s behavioral repertory as cognitive process ma-tures further. Although Freud believed that the sexual urges become relatively quiescent during this phase, observation indicates that they are expressed in derivative form in the child’s play. At puberty and through adolescence, genital urges once again predominate, but there is now a consolida-tion of sexual identity and a movement toward adult sexuality (Figure 18.1)


Libido Theory


Freud’s continued consideration of the sources and nature of the sexual drives led to his dynamic model of the mind referred to as



libido theory (Table 18.5). This theory attempted to explain the observation that behavior and mental activity are not only trig-gered by external stimuli (as in the reflex arc) but also generated by primary internal processes. Freud defined instinct as “a con-cept on the frontier between the mental and the somatic, as the psychical representative of the stimuli originating within the or-ganism and reaching the mind, as a measure of the demand made upon the mind for work in consequences of its connection with the body”. Regardless of the specifics of their origins, derivatives of the instincts are experienced mentally as compelling urges and a source of motivation.


Although Freud had given up the idea that sexual trau-matization was always the cause of psychoneurotic symptoms, he maintained the view that the sexual instinct played an etio-logical role in the neuroses and that sexual stimulation exerted a predominant force on mental activity throughout life. Freud termed this force libido. The discharge of libido is experienced as pleasure; the welling up of libido without discharge is felt as tension or unpleasure. According to the pleasure principle, the individual seeks pleasure (through the discharge of libidinal tension) and avoids unpleasure. The primary process quality of unconscious mentation follows the pleasure principle as it maintains its focus on the gratification of wishes. As the mind develops, conscious mentation becomes more governed by the reality principle (Freud, 1911) involving a shift from fantasy to perception of and action on reality. The secondary process form of conscious thought follows the reality principle. Under the influence of the reality principle, gratification of wishes may be delayed with the aim of eventually achieving greater and/or safer pleasure.


The sexual instinct has four defining components: source, pressure (or impetus), aim, and object. Source refers to the bio-logical substrate of the instinct. Pressure is the amount of force or “demand for work” of the instinct. The aim is the action designed to accomplish release of tension and satisfaction. An object is the target of desire, the person or thing through which gratification is accomplished. Although the libido theory has been criticized because it was based on 19th century German scientism, it has served as a useful metaphor to understand pleasure, attachments, and the dynamic processes of mental activity.


From the Topographical to the Structural Model


According to the topographical theory, three regions or systems of the mind exist as defined by their relationship to conscious thought: the conscious, preconscious and unconscious. The conscious mind registers sensations from the outside world and from internal processes, and is the agency of ordinary wakeful thought. Conscious mentation follows the reality principle and uses secondary process logic. The preconscious includes mental contents that can gain access into consciousness by the focus-ing of attention. The unconscious is defined from three basic angles: descriptively, it consists of all mental processes and con-tents operating outside conscious awareness; dynamically, these processes and contents are kept actively repressed or censored by the expenditure of mental energy to prevent the anxiety or repugnance that would accompany their conscious recognition; and as a mental system, it is a part of the mind that operates in accordance with the pleasure principle using primary process logic.


Over time, Freud encountered clinical phenomena that were not adequately accounted for by the topographical model. Freud revised his theory of mental systems to include the struc-tural model, but the useful conception of the dynamic uncon-scious and the particular qualities of conscious, preconscious and unconscious mentation have been retained.


Theory of Narcissism


In all mental functioning, it is possible to observe the balance be-tween libido deployed toward objects and libido directed toward the self. For example, when a person is in love, much libido is at-tached to the loved object, even to the extent that the person feels himself or herself diminished (from decreased ego libido). During physical illness or hypochondriacal states, libido is pulled toward the ego so the person appears preoccupied with the body and un-interested in the world. According to the pleasure principle, the mind seeks to discharge libido, and if it is dammed up, symptoms will result. In neurotic persons, excess object libido has accumu-lated and, undischarged, produces anxiety. In psychotic persons, ego libido has been prevented from being discharged outward, so it is discharged inward, resulting in hypochondriacal anxiety and megalomania.


Internal judgmental processes and self-regard are also ad-dressed by the theory of narcissism. In normal adults, most evi-dence of the operation of ego libido has been repressed. A new target of self-love has been constructed, the ego ideal, a forerun-ner of the superego concept, consisting of ideas and wishes for how one would like to be. Similarly, love objects may become the subject of idealization. Freud theorized a separate psychic agency, which he called the superego (see below), that attends to ensuring narcissistic satisfaction and measuring self-reflection, censoring and repression. Living up to the ideal, loving oneself and being loved, reflects attempts to restore a state comparable to the primary narcissism of infancy.




In Mourning and Melancholia Freud (1917), developed a theory to explain processes of guilt, internal self-punishment and de-pression. To do this, he contrasted states of grief or mourning with the condition of melancholia, now called depression. Both have in common the experience of pain and sadness, and both are brought on by the experience of loss, but the person in mourning maintains her or his positive self-regard, whereas the person with melancholia feels dejected, loses interest in the world, shows a di-minished capacity to love, inhibits all activities and exhibits low self-regard in the form of self-reproaches. In mourning, libido is gradually withdrawn from the object attachment; in melancho-lia, the ego feels depleted or comes under attack as though “one part of the ego sets itself over against the other, judges it criti-cally, and as it were, takes it as its object”. This critical agency (again a theoretical forerunner of the superego) comes to operate independently of the ego.


The self-accusations of the person with melancholia seem to fit best with criticism that might be leveled against the lost object. In the case of suicidal impulses, the melancholic person seems to be directing at himself or herself the sadism and mur-derous wishes felt toward the disappointing or lost other. Freud theorized that in the context of the loss of an ambivalently held object, the ego incorporates, or forms a narcissistic identifica-tion with, the object. Hostility originally felt toward the object is now directed at the self, giving rise to feelings of torment, suffering and self-debasement. A predisposition to melancholia may thus result from forming narcissistic object attachments and identifications.


Dual-instinct Theory


Freud had originally considered two types of instincts, the sexual and the ego (self-preservative) instincts, and considered sadism to represent a fusion of the two, with hostility occurring in the context of frustrated libidinal strivings. However, this theory did not adequately address psychological situations in which destructive tendencies seem to be operating independently of li-bidinal or self-preservative drives.


Freud concluded that there must be a separate instinct of aggression, whose aim is destructiveness. The aggressive drive is at work in impulses to harm, in the desire for control and power, in sadistic or masochistic behaviors, in guilt and depression, and in the persecutory fears of paranoid individuals.



Structural Model


On the basis of the preceding considerations, Freud revised his theory of the mind into what is now known as the structural or tripartite model (Table 18.6). He conceived of three mental agen-cies operating in the psyche: the id, the ego and the superego. The id is the biological source of instinctual drives, operating uncon-sciously and following the pleasure principle. The activity of the



id generates the motivational push for gratification of sexual and aggressive wishes.


The ego grows out of the id early in human development. Its functions include perception, interpretation of perceptions, voluntary movement, modulation of affects and impulses, cog-nition, memory, judgment and adaptation to reality. Subject to conflicting forces from the id, the superego and reality, the ego synthesizes mental compromises that provide gratification of instinctual wishes in accord with reality considerations and the moral demands of the superego.


The superego, which develops as an outgrowth of both the ego and id, consists of the moral standards, values and pro-hibitions that have been internalized throughout childhood and adolescence. It is the source of internal punishment, which is felt as guilt, and of internal reward. Early in development, the su-perego has a harsh and archaic quality. During maturation under optimal conditions, it becomes less harsh and comes to include loving components as well. In the structural model, the ego ideal (discussed earlier) is considered a component of the superego, accounting for feelings of shame and pride.


Anxiety and Symptom Formation


With the elaboration of the structural theory, Freud progres-sively viewed the nature of anxiety and the origin of symptoms (Figure 18.2) differently. According to his original theory, anxiety resulted from the accumulation of undischarged sexual tensions caused by inadequate sexual activity in the actual neu-roses or by inhibitions due to repression in the psychoneuroses. Later, it became clear that anxiety was more closely related to fear occurring in response to perceived dangers, either external or internal. This led to a focus on the ego, one of whose functions is to anticipate and negotiate danger situations. A dangerous or traumatic situation is one in which excessive stimulation threat-ens to overwhelm the ego’s capacity for delay and compromise.


The ego has as one of its tasks the continual formation of compromises among id wishes, the prohibitions and moral standards of the superego, and the dictates of reality. If these



compromises are successful, anxiety will operate predominantly on a signal level and behavior will be both sufficiently gratifying and acceptable in reality. A symptom neurosis occurs if these compromises are felt as uncomfortable, painful, or maladaptive.


Post-freudian Ego Psychology


Ego, Defense and Adaptation


Anna Freud laid out a categorization of defense mechanisms (1936) (Table 18.8). In discussing the preliminary stages of de-fense that are first used by the ego to avoid pain from the external world, she succeeded in integrating two main themes in the de-velopment of the ego concept: defense and relations with external reality. Anna Freud advocated a shift of the analyst’s attention to the ego as the proper field for observation, in order to gain a picture of its functioning in relation to the other two psychic structures, id and superego. This more detailed methodical at-tention to the mind’s surface, which includes manifestations of unconscious ego activities, provides a much clearer view of the actual workings of the mind. Her recommendation that the analyst listen from a point equidistant from id, ego and superego emphasized the importance of observing neutrally the influence of all three psychic agencies. The ego wards off not only deriv-atives of instinctual drives but also affects that are intimately connected with the drives. She advocated that priority be given to the interpretation of the defenses against affects, as well as defenses against instinctual drives.

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