Psychoanalytic Ideas Still Relevant To Clinical Practice In The 21St Century

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Psychoanalysis has all but disappeared as a therapeutic strategy, despite its place in social work and psychology. Although psychoanalytic ideas were once dominant in psychiatry in the early 20th century, the introduction of newer cognitive and behavioral treatments and an overriding focus on short-term interventions. With reference to previous literature, this essay will discuss a few psychoanalytic ideas which are still relevant to today's clinical practices and how they are used and how they may have been improved upon by more recent interventions.

One of the central tenets of psychoanalysis is how our childhoods have a crucial influence on our personalities as adults, whether it be childhood trauma or relationships with our parents. This is an idea that was carried on via Attachment Theory (Bowlby, 1969). While psychoanalysis influenced his ideas, Bowlby wrote off explanations like "drive theory" as "cupboard-love" theories of relationships, because he believed they wrongfully interpreted attachment as a primitively-driven instinct based on hunger or sexuality. Rather attachment, to Bowlby, is a psychological bond. Bowlby disagreed with psychoanalytic ideas of a linear development of personality, instead positing that developmental outcomes were contingent on the organism-environment interaction. Therefore, although children have an innate primary drive to form attachments, the nature and strength of those attachments the child's environmental factors such as socioeconomic status (Shaw & Vandra, 1993) or marital discord (Belsky & Isabella, 1988).

Psychoanalysis' dearth of persuasive evidence due to the shortage of empirical research into it. Attachment theory is a notable exception thanks to the "Strange Situations" paradigm. As the most commonly used way of analyzing attachment in infants (11 to 18 months old), it measures the organization of attachment behaviors using standardized laboratory conditions. The laboratory procedure had episodes of union, separation and reunion between the infant, caregiver and stranger to examine behavioral changes during these periods. Based on these behaviors, infants can be categorized into three 'organized' attachment styles: 'Secure', 'Insecure/Anxious-avoidant', and 'Insecure/Anxious-ambivalent'. Later, 'Disorganized' (Main & Solomon, 1990) was added. These styles can also be measured in adults using semi-constructed interviews or self-report measures to describe childhood relationships with parents and recall periods of separation. This is still relevant to modern-day clinical practice as it helps to potentially predict future behaviors.

Lyons-Ruth et al. (2013), for example, found that "for each additional withdrawing behaviour displayed by mothers in relation to their infant's attachment cues in the Strange Situation Procedure, the likelihood of clinical referral by service providers was increased by 50%." Further, early maternal withdrawal was predictive of borderline personality disorder in late adolescence. Early maternal withdrawal at 18 months remained a significant and strong independent predictor of suicidality, substance abuse, borderline personality and antisocial personality disorder. The Minnesota Study of Risk and Adaption from Birth to Adulthood concluded that, compared to securely-attached others, those with disorganized attachment were more likely to show dissociation, conduct disorder and self-injurious behaviors. Goodman, Bartlett and Stroh (2013) added that disorganized attachment and identity diffusion were both independent predictors of externalizing behaviors, particularly aggression. This is because insecure attachment styles teach children to expect or react with hostility during interactions, and infants are inexperienced at emotion regulation. In a meta-review, Mikulincer and Shaver (2007) found that attachment insecurity was common among people with mental disorders ranging from mild distress to schizophrenia. Similarly, both anxious and avoidant attachment insecurities have been associated with depression, clinically significant anxiety, obsessive-compulsive disorder, post-traumatic stress disorder, suicidal tendencies and eating disorders.

Some psychoanalysts have combined these epidemiological attachment style categories with psychoanalytic representations of dysfunctional relationships and their subsequent re-enactment in adult life. Attachment-based psychotherapy helps patients to understand their traumatic experiences by modifying their maladaptive emotions. Through attachment-based psychotherapy, Milrod et al. (2016) revealed a 67% decrease in salivary oxytocin levels in adults who had clinically severe separation anxiety and would not respond to other interventions – therapeutic or psychiatric. This evidence suggests the need for further research into oxytocin as an indicator or mediator of separation anxiety. It also gives support for attachment-based treatment strategies for otherwise-resistant anxiety.

While attachment theory has its empirical support, it is not without its limitations. Like other models psychoanalytically-derived, attachment theory does not account for the psychological and biological vulnerabilities that make mental disorders more likely to develop, thus limiting the applicability of attachment-based psychotherapy in clinical practice. Nor does the model, in its present form, take full account of gene-environment interactions in development because it tends not to consider that children can benefit as much from multiple attachment figures as from a mother (monotropy). While infants have one specific attachment at 8 months, by 18 months, only 13% still only have one significant attachment (Schaffer & Emerson, 1964). Rutter (1972) also indicated that infants will show distress at separation from peers, fathers and even inanimate objects – not just their mothers. Attachment theory runs the risk of being another psychodynamic model that, by emphasizing problems in early childhood, appears to only blame parents for psychopathology in their children when research has proved there to be many more risk factors.

As part of (attachment-based) psychoanalysis, therapists must listen and reflect on the experiences that make it difficult for the patient to form emotional bonds. The therapeutic aim is to get the patient to be more honest about his experiences, so he can discover the ones that are causing the dysfunction and recreate them from the therapist's perspective to reconcile any social or emotional disruptions. Such a practice can lead to the psychoanalytical concept of "transference". This can be defined as projecting feelings one has about a person onto an unrelated or involved second person. The therapist then interprets the client's behavior as a repetition or re-enactment of previous emotions from an earlier important relationship during childhood (and one can see the emphasis on childhood trauma or experience in psychoanalysis). For example, a client may routinely arrive to sessions thirty minutes early and gives rigid rehearsed answers. Interpretation could be she grew up with parents who only praised and acknowledged her when she overachieved, so further sessions are required to explore that. This phenomenon is still seen (at least partly) in modern clinical practices.

Psychodrama, for instance, builds upon transference using its core techniques: 'Role Reversal', 'Doubling', 'Mirror' and 'Soliloquy'. The former three technique represents different stages in Moreno's (1952) theory of the development of the infant: the stage of identity (the stage of doubling), the stage of the recognition of the self (the stage of mirroring), and the stage of the recognition of the other (the stage of role reversal). Role reversal requires that one has learned to differentiate in the areas of time, place and person, and can move out of his own position into another's position to be able to enact that other role. Clients who are capable of this task show a marked improvement in their social ability and theory of mind, hence why psychodrama is commonly used with those on the Autistic Spectrum.

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Through these techniques, psychoanalysis remains relevant in today's clinical practice by providing the framework for psychodrama's techniques. However, these techniques also beak down transference in a way that is more thorough and in-depth. Mirroring, for example, has the client act out an experience after which, he steps out of the scene and watches another actor steps into his role to portray him in that scene. This provides a third-person perspective on one's own behavior that transference does not give.

Role reversal is like transference because it allows the second person to see how the client behaves and feels how a target individual from their past (whether that be a parent, employer or partner). However, it is not identical, because it requires no transference interpretation since the client would inform the group of who the target person is and why they are significant so that the exercise will involve the correct roles. Psychodrama has arguably improved upon psychoanalysis because it avoids erroneous assumptions about the nature of the client's behavior which subsequently could damage what psychoanalysis calls the 'therapeutic alliance' between client and therapist. While Hogeland (1993) claimed interpretations "will guarantee stability and an ability to protect against future stressful events and the vicissitudes of life", empirical studies have found a negative correlation between the number of transference interpretations and positive outcomes in therapy. Psychodrama, contrastingly, would avoid making numerous interpretive assumptions because dramatic roles and their significance would be agreed upon enactment begins.

Psychodrama does, however, have its own variation of transference interpretations in 'Doubling', wherein participants, at the request of the 'director'/therapist, supplements the role of the 'protagonist'/client, usually by standing behind them speaking on behalf of protagonist. The supplemental role is fulfilled by the 'Double'. His must link the protagonist's internal thoughts and hidden desires with their external environment. This way one can hear things that may (or not) reflect their emotions or thoughts. Thereby, the doubling can foster clarifications, epiphanies, "abreactive" (relieving emotional excess by reliving experiences) and mental catharsis. Critically, doubling may also be an improvement on transference interpretations because client may not view supplementary assumptions to be as invasive or probing due to the playful environment that theatre brings – especially when compared to the more clinical setting of typical psychoanalysis sessions. However, newer forms of Doubling focus not so much on an abreactive catharsis but more on an integrative catharsis since psychodrama has learned that too much emotion can be re-traumatizing to the client.

As mentioned before, psychodrama can be emotionally overcharging, and this is not its only limitation. As with psychoanalysis, psychodrama advocates typically rely on anecdotal experiences to endorse the effectiveness of the practice. This reliance unsatisfactory evidence is due to a paucity of empirical research.

The participant selection process can be time-consuming since potential group members must be open to working on sensitive issues. As such, these members must be pre-screened, and therapists are ethically bound to reassigning unsuitable participants into individual therapies. Thus, the remaining group must wait longer for empty roles to be filled. Similarly, the warm up sessions will be lengthy because group members will need to build rapport with multiple people instead of just one therapist. Every session is group work which risks the needs of the individual being overshadowed by the progress of the collective. As with psychoanalysis, too much weight is placed on talk therapy. While studies would suggest it is at least as effective as short-term antidepressants, psycho-pharmacology is not considered as much as it should. While psychodrama may improve on principles from psychoanalysis, its limitations make its utility questionable and could leave psychoanalysis with one fewer means of relevancy.

Another relevant psychoanalytic idea is that of 'Free Association'. Described as the "talking cure" (Breuer & Freud, 1985) free association invites clients to openly share their thoughts during sessions without censorship. It aims to introduce patients to non-judgmental atmospheres where therapists can explore their thoughts and emotions. Psychoanalysis posits that people are often afraid of self-exposure – harkening back to the Ego and Superego of Freud's Structural Model (Freud, 1923). As such, there will be resistant patients who may not find Free Association useful, but such behavior (e.g., an excessively long pause) often indicates that the session is touching on an important repressed thought, so further probing is therapeutically beneficial.

The principle of Free Association is still seen in prospective psychological tests such as the widely-used Thematic Appreciation Test (TAT) and the well-known Rorschach Inkblot Test (Rorschach, 1924). Rorschach tests consist of 10 inkblots printed on cards with five in black and white, five in color. After the test subject has seen and responded to all the inkblots (free association phase), the tester then presents them again sequentially for the client to study and note where he sees what he originally saw in the free association phase, and what makes it look like that (inquiry phase). Meanwhile, the psychologist writes down everything the client says or does, no matter how trivial. The aim is to produce data on personality factors such as motivations, affectivity and interpersonal perceptions. The underlying assumption is that an individual will interpret external stimuli (the inkblots) based on person-specific perceptions, which are based on needs, base motives, and conflicts.

This method has spawned controversy among psychologists. First, the test still is not diagnostic and only aims to further develop an understanding of the client's personality, not identify disorders. Second, some criticize its heavy reliance on the assessor's subjective interpretation of the clients' behavior. Further, this subjectivity alongside needing identical verbal and nonverbal free associations from the client severely lowers the test's external and inter-rater reliability – which would further explain the decline of psychoanalysis. The use of free associations coincides with the "Fundamental Rule" (Freud, 1914) that has the client promise to be wholly transparent and honest with their responses. This compulsion to give images meaning can invalidate the data as false associations are recorded because clients are saying anything to fill the silence.

In contrast to Rorschach's significant criticism, the TAT is still used today, especially with children. Here, the subject is asked to tell dramatic stories for 32 pictures, including elements like what events led up to this moment, current happenings, and characters' thoughts and emotions about the eventual outcome. Examiners must avoid answering any questions about the pictures or interrupting unless participants omit any story elements. In which case, they may directly ask participants (children and the cognitively-deficient especially).

The Thematic Appreciation Test has been criticized for its poor reliability and validity. Reliability is poor because the test does not account for changing life situations and needs to change TAT responses. Jenkins (2008) has indicated that the validity of the test is based on the judgment of the psychologist and how well his decisions were assisted based on the TAT. Worse still, evidence suggests that this is a poor guide as clinicians could only correctly classify clients as clinical or non-clinical at close to chance levels (57%) using only TAT data (Wildman & Wildman, 1975). TAT is also considered unscientific because conclusions drawn from the car stories cannot be disproven since they are conscious and unconscious motives. Furthermore, characteristics such as the Walter Mitty effect (i.e. asserting that a client will show personality traits incongruent with their behavior because TAT stories reflect what the clinician wishes to be the case rather than reality) and the inhibition effect (the claim that the clients demonstrate low trait levels because they are repressing that trait). Despite these limitations, TAT continues to be a research tool in psychological areas including dreams, personality disorders and thought disorders.

In conclusion, this was a narrow look into some of the psychoanalytic ideas that remain relevant in today's clinical practice. There are others such as dream-centered discussion and defense mechanisms, but this essay focused on psychoanalysis' interest in childhood experience, interpretation and free association. While psychoanalysis has seen a significant decline in therapeutic use, its ideas still permeate psychology because they form the framework for newer strategies such as Attachment Theory and Thematic Appreciation Tests. These strategies then improve on some of the limitations of their predecessor and allow it to have greater benefits than it would have done independently.

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