Psychoanalysis

# Overview
Psychoanalysis today comprises several interlocking theories concerning the functioning of the mind; the term also refers to a specific type of treatment where the analyst, upon hearing the thoughts of the analysand (analytic patient), formulates and then explains the unconscious bases for the patient's symptoms and character problems.  Unconscious functioning was first described by Sigmund Freud, who modified his theories several times over a period of almost 50 years of attempting to treat patients who suffered with mental problems. During psychoanalytic treatment, the patient tells the analyst various thoughts and feelings.  The analyst listens carefully, formulates, then intervenes to attempt to help the patient develop insight into unconscious factors causing the problems.  The specifics of the analyst's interventions typically include confronting and clarifying the patient's pathological defenses, wishes and guilt.  Through the analysis of resistance (unconscious barriers to treatment), and transference to the analyst of expectations, psychoanalysis aims to unearth wishes and emotions from prior unresolved conflicts, in order to help the patient perceive and resolve lingering problems.
Although recently the subject of widespread criticism, psychoanalysis has been thriving as a research tool into childhood development (cf. the journal The Psychoanalytic Study of the Child), and has developed into a flexible, effective treatment for certain mental disturbances (see Wallerstein's (2000)Forty-Two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy).  In the 1960s, Freud's early (1905) thoughts on the childhood development of female sexuality were challenged; this challenge led to the development of a variety of alternative models of psychoanalysis, many of which challenged Freud's thinking about female sexual development,  and other fundamental questions.  Most contemporary psychoanalysts employ theories that, while based on those of Sigmund Freud, also differ from his in significant respects.
Today, there are approximately 45 accredited training institutes for psychoanalysis in the United States (see www.apsa.org), and there are over 3,000 graduated psychoanalysts practicing in the United States.  The International Psychoanalytical Association accredits psychoanalytic training centers throughout the world, including countries such as Serbia, France, Germany, Austria, Italy, Switzerland, and many others, and is a fast-growing organization.

# Origins
Psychoanalysis was devised in Vienna in the 1890s by Sigmund Freud, a neurologist interested in finding an effective treatment for patients with neurotic or hysterical symptoms. Freud became sensitized to the existence of mental processes that were not conscious as a result of his neurological consulting job at the Kinderkrankenhaus (Children's Hospital), where he noticed that many aphasic children had no organic cause for their symptoms.  (He wrote a monograph about this, called, "On Aphasia.")  He also became aware of the experimental treatment (combination of hypnotism and "catharsis" done by "abreaction") his older mentor and colleague, Dr. Josef Breuer, was using to treat the now famous patient, Anna O.  In the late 1880s, Freud obtained a grant to study with Jean-Martin Charcot, the famed neurologist and syphilologist, at the Salpetriere in Paris.  Dr. Charcot had become interested in patients who had symptoms that mimicked general paresis, the psychotic illness that occurs due to tertiary syphilis.  Charcot had found that many patients experienced paralyses, pains, coughs, and a variety of other symptoms with no demonstrable physical etiology (cause).  Prior to Charcot's work, women were thought to have a wandering uterus (the name hysteria means this in Greek).  But Freud learned that men could have psychosomatic symptoms as well.   As a result of talking with patients, Freud learned that the majority complained of sexual problems (especially coitus interruptus as birth control), which surprised him greatly.  He first suspected their problems stemmed from cultural restrictions on sexual expression, and devised what today is called "topographic theory," in 1895.  In this theory, which he later more or less discarded (in 1923), unacceptable sexual wishes were repressed into the "System Unconscious" unconscious due to "society's" condemnation of premarital sexual activity, and this repression created anxiety.  Freud also discovered what most of us take for granted today:  that dreams were symbolic and specific to the dreamer.  Often, dreams give clues to unconscious conflicts, and for this reason, Freud referred to dreams as the "royal road to the Unconscious."  After several theoretical modifications, the discovery of narcissism (1915), and the study of paranoia, masochism, and depression (1917), Freud eventually reorganized his data into what became known as structural theory (in a small book called The Ego and the Id, 1923).  This new theory, which addressed the cause of neurotic symptoms (phobias, compulsions, obsessions, depressions, and "hysterical" conversions, e.g.), suggested that such problems were created by conflicts among various wishes and guilt, which produced anxiety.  To handle the anxiety, the mind forgot (repressed) certain conflicting thoughts.  In other words, now he felt that anxiety produced repression, not the other way around.

# Theories
The predominant psychoanalytic theories include
- Conflict Theory, which theorizes that emotional symptoms and character traits are complex solutions to intrapsychic conflict.  See Brenner (2006), Psychoanalysis: Mind and Meaning, New York: Psychoanalytic Quarterly Press.  This revision of Freud's structural theory (Freud, 1923, 1926) dispenses with the concepts of a fixed id, ego and superego, and instead posits unconscious and conscious conflict among wishes (dependant, controlling, sexual, and aggressive), guilt and shame, emotions (especially anxiety and depressive affect), and defensive operations that shut off from consciousness some aspect of the others.  Moreover, healthy functioning (adaptive) is also determined, to a great extent, by resolutions of conflict.  A major goal of modern conflict theorist analysts is to attempt to change the balance of conflict through making aspects of the less adaptive solutions (also called compromise formations) conscious so that they can be rethought, and more adaptive solutions found.  Current theoreticians following Brenner's many suggestions (see especially Brenner's 1982 book, "The Mind in Conflict") include Sandor Abend, MD (Abend, Porder, & Willick, (1983), Borderline Patients: Clinical Perspectives), Jacob Arlow (Arlow and Brenner (1964), Psychoanalytic Concepts and the Structural Theory), and Jerome Blackman (2003), 101 Defenses: How the Mind Shields Itself).  Conflict theory is the prevalent analytic theory taught in psychoanalytic intitutes, throughout the United States, accredited by the American Psychoanaltyic Association.
- Ego Psychology, which has a long history.  Begun by Freud in Inhibitions, Symptoms and Anxiety (1926), the theory was refined by Hartmann, Loewenstein, and Kris in a series of papers and books from 1939 through the late 1960s.  Leo Bellak picked up the work from there.  This series of constructs, parallelling some of cognitive theory, includes the notions of autonomous ego functions:  mental functions not dependant, at least in origin, on intrapsychic conflict.  Such functions include:  sensory perception, motor control, symbolic thought, logical thought, speech, abstraction, integration (synthesis), orientation, concentration, judgment about danger, reality testing, adaptive ability, executive decision-making, hygiene, and self-preservation.  Freud noted inhibition as a way the mind may interfere with any of these functions to avoid painful emotions.  Hartmann (1950s) pointed out that there may be delays or deficits in such functions.  Frosch (1964) described differences in those people who demonstrated damage to their relationship to reality, but who seemed able to test it.  Deficits in the capacity to organize thought are sometimes referred to as blocking or loose associations (Bleuler), and are characteristic of the schizophrenias.  Deficits in abstraction ability and self-preservation also suggest psychosis in adults.  Deficits in orientation and sensorium are often indicative of a medical illness affecting the brain (and therefore, autonomous ego functions).  Deficits in certain ego functions are routinely found in severely sexually or physically abused children, where powerful affects generated throughout childhood seem to have eroded some functional development.  Ego strengths, later described by Kernberg (1975), include the capacities to control oral, sexual and destructive impulses; to tolerate painful affects without falling apart; and to prevent the eruption into consciousness of bizarre symbolic fantasy.  Defensive activity, which shuts certain conflictual thoughts,fantasies, and sensations out of consciousness, is also sometimes included here, although defensive operations are different from autonomous functions.  Nevertheless, the term "ego defense" has become common.
- Object relations theory, which attempts to explain vicissitudes of human relationships through a study of how internal representations of self and of others are structured.  The clinical problems that suggest object relations problems (usually developmental delays throughout life) include disturbances in an individual's capacity to feel warmth, empathy, trust, sense of security, identity stability, consistent emotional closeness, and stability in relationships with chosen other human beings.  (It is not suggested that one should trust everyone, for example).  Concepts regarding internal representations (also sometimes termed, "introjects," "self and object representations," or "internalizations of self and other") although often attributed to Melanie Klein, were actually first mentioned by Sigmund Freud in his early concepts of drive theory (1905, Three Essays on the Theory of Sexuality).  Freud's 1917 paper "Mourning and Melancholia", for example, hypothesized that unresolved grief was caused by the survivor's internalized image of the deceased becoming fused with that of the survivor, and then the survivor shifting unacceptable anger toward the deceased onto the now complex self image.  Vamik Volkan, in "Linking Objects and Linking Phenomena," expanded on Freud's thoughts on this, describing the syndromes of "Established pathological mourning" vs. "reactive depression" based on similar dynamics.  Melanie Klein's hypotheses regarding internalizations during the first year of life, leading to paranoid and depressive positions, were later challenged by Rene Spitz (e.g., The First Year of Life, 1965), who divided the first year of life into a coenesthetic phase of the first 6 months, and then a diacritic phase for the second 6 months.  Margaret Mahler (Mahler, Fine, and Bergman (1975), "The Psychological Birth of the Human Infant") and her group, first in New York, then in Philadelphia, described distinct phases and subphases of child development leading to "separation-individuation" during the first three years of life, stressing the importance of constancy of parental figures, in the face of the child's destructive aggression, to the child's internalizations, stability of affect management, and ability to develop healthy autonomy.  Later developers of the theory of self and object constancy as it affects adult psychiatric problems such as psychosis and borderline states have been John Frosch, Otto Kernberg, and Salman Akhtar.  Peter Blos described (1960, in a book called "On Adolescence) how similar separation-individuation struggles occur during adolescence, of course with a different outcome from the first 3 years of life:  the teen usually, eventually, leaves the parents' house (this varies with the culture).  During adolescence, Erik Erikson (1950, 1960s) described the "identity crisis," that involves identity-diffusion anxiety.  In order for an adult to be able to experience "Warm-ETHICS" (warmth, empathy, trust, holding environment (Winnicott), identity, closeness, and stability) in relationships (see Blackman (2003), 101 Defenses: How the Mind Shields Itself), the teenager must resolve the problems with identity and redevelop self and object constancy.
- Structural Theory, which breaks the mind up into the id, the ego, and the superego.  Actually, in German, the word for id is "es," which means "it."  The word ego was coined by Freud's translators; Freud used the term, "ich" meaning "I" in English.  Freud called the superego the "Uber-ich."  The id was designated as the repository of sexual and aggressive wishes, which Freud called "drives."  The ego was composed of those forces that opposed the drives -- defensive operations.  The superego was Freud's term for the conscience -- values and ideals, shame and guilt.  One problem Brenner (2006) later found with this theory (see above) was that Freud also suggested that forgotten thoughts ("the repressed") were also "located" in the id.  However, Freud here realized that drives could be conscious or unconscious, and that consciousness vs. unconsciousness was a quality of any mental operation or any mental conflict.  Forgetting things could be done on purpose, or not.  People could be aware of guilt, or not aware.
- Self psychology, which emphasizes the development of a stable sense of self through mutually empathic contacts with other humans, was developed originally by Heinz Kohut, and has been elucidated by the Ornsteins and Arnold Goldberg.  Marian Tolpin explicated the need for "transmuting internalizations" (1971) during treatment, to correct what Kohut referred to as a disturbance in the "self-object" internalizations from parents.
- Lacanian psychoanalysis, which integrates psychoanalysis with semiotics and Hegelian philosophy, is popular in France.
- Analytical psychology, which has a more spiritual approach, founded by Carl Jung
- Interpersonal psychoanalysis, which accents the nuances of interpersonal interactions, was first introduced by Harry Stack Sullivan, MD, and developed further by Frieda Fromm-Reichmann.  It is the primary theory, still taught, at the William Alanson White Center.
- Relational psychoanalysis, which combines interpersonal psychoanalysis with object-relations theory as critical for mental health, was developed primarily by Stephen Mitchell.  His suggestions for technique applied to patients who seemed unable to develop trusting, close relationships.  Fonagy and Target, in London, have propounded their view of the necessity of helping certain detached, isolated patients, develop the capacity for "mentalization" associated with thinking about relationships and themselves.
- Modern psychoanalysis, a body of theoretical and clinical knowledge developed by Hyman Spotnitz and his colleagues, extended Freud's theories so as to make them applicable to the full spectrum of emotional disorders. Modern psychoanalytic interventions are primarily intended to provide an emotional-maturational communication to the patient, rather than to promote intellectual insight.
Although these theoretical "schools" differ, most of them continue to stress the strong influence of unconscious elements affecting people's mental lives.  There has also been considerable work done on consolidating elements of conflicting theory (cf. the work of Theodore Dorpat, B. Killingmo, and S. Akhtar).  As in all fields of medicine (for example, }, there are some persistent conflicts regarding specific causes of some syndromes, and disputes regarding the best treatment techniques.
Today psychoanalytic ideas are embedded in the culture, especially in childcare, education, literary criticism, and in psychiatry, particularly medical and non-medical psychotherapy. Though there is a mainstream of evolved analytic ideas, there are groups who more specifically follow the precepts of one or more of the later theoreticians.  It also plays a role in literary analysis.  See Archetypal literary criticism.

## Psychopathology (mental disturbances)
The various psychoses involve deficits in the autonomous ego functions (see above) of integration (organization) of thought, in abstraction ability, in relationship to reality and in reality testing.  In depressions with psychotic features, the self-preservation function may also be damaged (sometimes by overwhelming depressive affect).  Because of the integrative deficits (often causing what general psychiatrists call "loose associations," "blocking," "flightof ideas," "verbigeration," and "thought withdrawal,"), the development of self and object representations is also impaired.  Clinically, therefore, psychotic individuals manifest limitations in warmth, empathy, trust, identity, closeness and/or stability in relationships (due to problems with self-object fusion anxiety) as well.
In patients whose autonomous ego functions are more intact, but who still show problems with object relations, the diagnosis often falls into the category known as "borderline."  Borderline patients also show deficits, often in controlling impulses, affects, or fantasies -- but their ability to test reality remains more or less intact.
Those adults who do not experience guilt and shame, and who indulge in criminal behavior, are usually diagnosed as psychopaths, or, using DSM-IV-TR, antisocial personality disorder.
Panic, phobias, conversions, obsessions, compulsions and depressions (analysts call these "neurotic syptoms") are not usually caused by deficits in functions.  Instead, they are caused by intrapsychic conflicts.  The conflicts are generally among sexual and hostile-aggressive wishes, guilt and shame, and reality factors.  The conflicts may be conscious or unconscious, but create anxiety, depressive affect, and anger.  Finally, the various elements are managed by defensive operations -- essentially shut-off brain mechanisms that make people unaware of that element of conflict.  "Repression" is the term given to the mechanism that shuts thoughts out of consciousness.  "Isolation of affect" is the term used for the mechanism that shuts sensations out of consciousness.  Neurotic symptoms may occur with or without deficits in ego functions, object relations, and ego strengths.  Therefore, it is not uncommon to encounter obsessive-compulsive schizophrenics, panic patients who also suffer with borderline personality disorder, etc.
Furthermore, we know that many adult problems can trace their origins to unresolved conflicts from certain phases of childhood and adolescence.  Freud, based on the data gathered from his patients early in his career, suspected that neurotic disturbances occurred when children were sexually abused in childhood (the so-called seduction theory).  Later, Freud came to realize that, although child abuse occurs, that not all neurotic symptoms were associated with this.  He realized that neurotic people often had unconscious conflicts that involved incestuous fantasies deriving from different stages of development.  He found the stage from about 3 to 6 years of age (preschool years, today called the "first genital stage") to be filled with fantasies about marriage with both parents.  Although arguments were generated in turn-of-the-(20th)century Vienna about whether adult seduction of children was the basis of neurotic illness, there is virtually no argument about this problem in the 21st century.
Many psychoanalysts who work with children have studied the actual effects of child abuse, which include ego and object relations deficits and severe neurotic conflicts.  Much research has been done on these types of trauma in childhood, and the adult sequelae of those.  On the other hand, many adults with symptom neuroses and character pathology have no history of childhood sexual or physical abuse.
In studying the childhood factors that start neurotic symptom development, Freud found a constellation of factors that, for literary reasons, he termed the Oedipus complex (based on Sophocles play, Oedipus Rex, where the protagonist unwittingly kills his father Laius and marries his mother Jocasta).  The shorthand term, "oedipal," (later explicated by Joseph Sandler, 1960, in "On the Concept Superego" and modified by Charles Brenner (1982) in "The Mind in Conflict") refers to the powerful attachments that children make to their parents in the preschool years.  These attachments involve fantasies of marriage to either (or both) parent, and, therefore, competitive fantasies toward either (or both) parents.  Humberto Nagera (1975) has been particulary helpful in clarifying many of the complexities of the child through these years.
The terms 'positive' and 'negative' oedipal conflicts have been attached to the heterosexual and homosexual aspects, respectively.  Both seem to occur in development of most children.  Eventually, the developing child's concessions to reality (that they will neither marry one parent nor eliminate the other) lead to identifications with parental values.  These identifications generally create a new set of mental operations regarding values and guilt, subsumed under the term "superego."  Besides superego development, children "resolve" their preschool oedipal conflicts through channeling wishes into something their parents approve of ("sublimations") and the development, during the school-age years ("latency") of age-appropriate obsessive-compulsive defensive maneuvers (rules, repetitive games).
When there is disturbance in the family during the first genital phase (such as death of a parent or divorce), unusual magnification of anxieties in the child may occur.  This sets the stage for problems during latency and adolescence.  Later in life, under certain circumstances, a recrudescence of symptoms may occur during periods that are either stressful or symbolic -- such as marriage, having children, or graduating from school.
Controversies regarding infantile sexuality and the oedipus complex are prevalent within and without psychoanalytic circles.

# Indications and contraindications for analytic treatment
Using the various analytic theories to assess mental problems, several particular constellations of problems are particularly suited for analytic techniques (see below) whereas other problems respond better to medicines and different interpersonal interventions.
To be treated with psychoanalysis, whatever the presenting problem, the person requesting help must demonstrate
- good capacity to organize thought (integrative function)
- good abstraction ability
- reasonable ability to observe self and others
- some capacity for trust and empathy
- some ability to control emotion and urges, and
- good contact with reality (excludes most psychotic patients)
- some guilt and shame (excludes most criminals)
- reasonable self-preservation ability (excludes severely suicidal patients)
If any of the above are faulty, then modifications of techniques, or completely different treatment approaches, must be instituted.  The more there are deficits of serious magnitude in any of the above mental operations (1-8), the more psychoanalysis as treatment is contraindicated, and the more medication and supportive approaches are indicated.  In non-psychotic first-degree criminals, any treatment is often contraindicated.
The problems treatable with analysis include:  phobias, conversions, compulsions, obsessions, anxiety attacks, depressions, sexual dysfunctions, a wide variety of relationship problems (dating and marital strife, e.g.), and a wide variety of character problems (e.g., painful shyness, meanness, obnoxiousness, workaholism, hyperseductiveness, hyperemotionality, hyperfastidiousness).  The fact that many of such patients also demonstrate deficits in numbers 1-8 above makes diagnosis and treatment selection difficult.

# Technique
The basic method of psychoanalysis is interpretation of the analysand's unconscious conflicts that are interfering with current-day functioning --  conflicts that are causing painful symptoms such as phobias, anxiety, depression, and compulsions.  Strachey (1936) stressed that figuring out ways the patient distorted perceptions about the analyst led to understanding what may have been forgotten (also see Freud's paper "Repeating, Remembering, and Working Through").  In particular, unconscious hostile feelings toward the analyst could be found in symbolic, negative reactions to what Robert Langs later called the "frame" of the therapy -- the setup that included times of the sessions, payment of fees, and necessity of talking.  In patients who made mistakes, forgot, or showed other peculiarities regarding time, fees, and talking, the analyst can usually find various unconscious "resistances" to the flow of thoughts (sometimes called free association).
When the patient reclines on a couch with the analyst out of view, the patient tends to remember more, experience more resistance and transference, and be able to reorganize thoughts after the development of insight -- through the interpretive work of the analyst.  Although fantasy life can be understood through the examination of dreams, masturbation fantasies (cf. Marcus, I. and Francis, J. (1975), Masturbation from Infancy to Senescence) are also important.  The analyst is interested in how the patient reacts to and avoids such fantasies (cf. Paul Gray (1995), The Ego and the Analysis of Defense).  Various memories of early life are generally distorted -- Freud called them "screen memories" -- and in any case, very early experiences (before age 2) -- can not be remembered (See the child studies of Eleanor Galenson on "evocative memory").

## Variations in technique
There is what is known among psychoanalysts as "classical technique," although Freud throughout his writings deviated from this considerably, depending on the problems of any given patient.  Classical technique was best summarized by Allan Compton, MD, as comprising:
- instructions (telling the patient to try to say what's on their mind, including interferences)
- exploration (asking questions)
- clarification (rephrasing and summarizing what the patient has been describing)
- confrontation (bringing an aspect of functioning, usually a defense, to the patient's attention)
- dynamic interpretation (explaining how being too nice guards against guilt, e.g.  - defense vs. affect)
- genetic interpretation (explaining how a past event is influencing the present)
- resistance interpretation (showing the patient how they are avoiding their problems)
- transference interpretation (showing the patient ways old conflicts arise in current relationships, including that with the analyst)
- dream interpretation (obtaining the patient's thoughts about their dreams and connecting this with their current problems)
- reconstruction (estimating what may have happened in the past that created some current day difficulty)
Clearly, these techniques are primarily based on conflict theory (see above).  As object relations theory evolved, supplemented by the work of Bowlby, Ainsorth, and Beebe, techniques with patients who had more severe problems with basic trust (Erikson, 1950) and a history of maternal deprivation (see the works of Augusta Alpert) led to new techniques with adults.  These have sometimes been called interpersonal, intersubjective (cf. Stolorow), relational, or corrective object relations techniques.  These techniques include:
- expressing an experienced empathic attunement to the patient
- expressing a certain dosage of warmth
- exposing a bit of the analyst's personal life or attitudes to the patient
- allowing the patient autonomy in the form of disagreement with the analyst (cf. I.H. Paul, Letters to Simon.)
- explanations of the motivations of others which the patient misperceives
Finally, ego psychological concepts of deficit in functioning led to refinements in supportive therapy.  These techniques are particularly applicable to psychotic and near-psychotic (cf., Eric Marcus, "Psychosis and Near-psychosis") patients.  These supportive therapy techniques include:
- discussions of reality
- encouragement to stay alive (including hospitalization)
- psychotropic medicines to relieve overwhelming depressive affect
- psychotropic medicines to relieve overwhelming fantasies (hallucinations and delusions)
- advice about the meanings of things (to counter abstraction failures)
The notion of the "silent analyst" has been made into negative propaganda against analysis.  Actually, the analyst listens in a special way (see Arlow's paper on "The Genesis of Interpretation").  Much active intervention is necessary by the analyst to interpret resistances, defenses creating pathology, and fantasies that are being displaced into the current day inappropriately.  Silence and non-responsiveness was actually a technique promulgated by Carl Rogers, in his development of so-called "Client Centered Therapy" -- and is not a technique of psychoanalysis (also see the studies and opinion papers of Owen Renik, MD).
"Analytic Neutrality" is a concept that does not mean the analyst is silent.  It refers to the analyst's position of not taking sides in the internal struggles of the patient.  For example, if a patient feels guilty, the analyst might explore what the patient has been doing or thinking that causes the guilt, but not reassure the patient not to feel guilty.  The analyst might also explore the identifications with parents and others that led to the guilt.
Although single-client sessions remain the norm, psychoanalytic theory has been used to develop other types of psychological treatment.  Psychoanalytic group therapy was pioneered by Harry Stack Sullivan, S. R. Slavson, and Wolfe.  Child-centered counseling for parents was instituted early in analytic history by Freud, and was later further developed by Irwin Marcus, Edith Schulhofer, and Gilbert Kliman.  Psychoanalytically based couples therapy has been promulgated and explicated by Fred Sander, MD.

## Training
Psychoanalytic training in the United States, in most locations, involves three facets:
- Personal analytic treatment for the trainee, conducted confidentially, with no report to the Education Committee of the Analytic Training Institute.
- Approximately 600 hours of class instruction, with a standard curriculum, over a 4-year period.  Classes are often a few hours per week, or for a full day or two every other weekend during the academic year; this varies with the institute.
- Supervision once per week, with a senior analyst, on each analytic treatment case the trainee has.   The minimum number of cases varies between institutes, often 2 to four cases.  Male and female cases are required.  Supervision must go on for at least a few years on one or more cases.  Supervision is done in the supervisor's office, where the trainee presents material from the analytic work that week, examines the unconscious conflicts with the supervisor, and learns, discusses, and is advised about technique.
Psychoanalytic Training Centers in the United States have been accredited by special committees of the American Psychoanalytic Association or the International Psychoanalytical Association.  Because of theoretical differences, other institutes have arisen, as well, which belong to other organizations such as the American Academy of Psychoanalysis and Dynamic Psychotherapy, and the National Association for the Advancement of Psychoanalysis.  At most psychoanalytic institutes in the United States, qualifications for entry include a terminal degree in a mental health field, such as Ph.D., C.S.W., or M.D.   A few institutes restrict applicants to those already holding an M.D. or Ph.D., and one institute in Southern California confers a Ph.D. or Psy.D. in psychoanalysis upon graduation, which involves completion of the necessary requirements for the state boards that confer that doctoral degree.  In many institutes in Europe and Latin America, the admission for training does not necessarily require a license-bearing preliminary degree.
Some psychoanalytic training has been set up as a post-doctoral fellowship in university settings, such as at Duke University, Yale University , New York University, and Columbia University.  Other psychoanalytic institutes may not be directly associated with universities, but the faculty at those institutes usually hold contemporaneous faculty positions with psychology Ph.D. programs and/or with Medical School psychiatry residency programs.
Psychoanalysis was limited to those "in the know" from the early 1920s (when A.A. Brill began the New York Psychoanalytic Institute) through the end of World War II, although the idea that repression of sexual urges could make you mentally ill (Freud's first, discarded theory) proved popular with college students in the 1920s -- who used the theory to argue with their conservative parents.  During those early years, Andrew Carnegie was perhaps one of the most famous patients who benefited; he later made his gratitude public by endowing a psychoanalytic fund in Pittsburgh.
Psychoanalysis became popular post-war, as many celebrities found it useful -- such as Steve Allen, Jane Meadows, and Art Buchwald.  Psychoanalytic treatment became somewhat less popular during the 1980s and early 1990s.  Circa 1986, when insurance companies decimated health insurance coverage for all mental illnesses (in part due to corrupt practices in some for-profit hospitals), people for whom psychoanalytic treatment was indicated were increasingly unable to afford it.  Gradually, as psychiatry departments became more dependent on grants from pharmaceutical companies, chairs of Psychiatry Departments in the nation's medical schools tended to come from backgrounds involving pharmacological research -- not from backgrounds involving analytic training.  Interestingly, psychoanalytic institutes have experienced an increase in the number of applicants in recent years, but, not surprisingly, about 70-80% of incoming students are non-MDs.

# Efficacy and empirical research
Over a hundred years of case reports and studies in the Psychoanalytic Quarterly, the International Journal of Psychoanalysis and the Journal of the American Psychoanalytic Association demonstrate the efficacy of analysis in cases of neurosis and character or personality problems. Psychoanalysis modified by object relations techniques has been shown to be effective in many cases of ingrained problems of intimacy and relationship (cf. the many books of Otto Kernberg).  As a therapeutic treatment, psychoanalytic techniques may be useful in a one-session consultation (see Blackman, J. (1994), Psychodynamic Technique during Ungent Consultation Interviews, Journal Psychotherapy Practice & Research).  Psychoanalytic treatment, in other situations, may run from about a year to many years, depending on the severity and complexity of the pathology.
Psychoanalytic theory has, from its inception, been the subject of criticism and controversy.  Freud remarked on this early in his career, when other physicians in Vienna ostracized him for his findings that hysterical conversion symptoms were not limited to women.   Challenges to analytic theory began with Otto Rank and Adler (turn of the 20th century), continued with behaviorists (Wolpe, e.g.) into the 1940s and '50s, and have persisted.  Criticisms come from those who object the notion that there are mechanisms, thoughts or feelings in the mind that could be unconscious.  Criticisms also have been leveled against the discovery of "infantile sexuality" (the recognition that children between ages 2 and 6 years of age imagine things about procreation).   Criticisms of theory have led to opposing analytic theories, such as the work of Fairbairn, Balint, and Bowlby.   In the past 30 years or so, the criticisms have centered on the issue of empirical verification, in spite of many empirical, prospective research studies that have been empirically validated (e.g., See the studies of Barbara Milrod, at Cornell University Medical School, et al.).
Psychoanalysis has been thriving as a research tool into childhood development (cf. the journal The Psychoanalytic Study of the Child), and has developed into a flexible, effective treatment for certain mental disturbances (see Wallerstein's (2000) Forty-Two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy).  In the 1960s, Freud's early (1905) thoughts on the childhood development of female sexuality were challenged; this challenge led to major research in the 1970s and 80s, and then to a reformulation of female sexual development that corrected of Freud's concepts.
Analysis of previous randomized controlled trials have suggested that psychoanalytic treatment is effective in specific psychiatric disorders. .  Empirical research on the efficacy of psychoanalysis and psychoanalytic psychotherapy has also become prominent among psychoanalytic researchers.
Research on psychodynamic treatment of some populations shows mixed results. Research by analysts such as Bertram Karon and colleagues at Michigan State University had suggested that when trained properly, psychodynamic therapists can be effective with schizophrenic patients. More recent research casts doubt on these claims.  The Schizophrenia Patient Outcomes Research Team (PORT) report argues in its Recommendaton 22 against the use of psychodynamic therapy in cases of schizophrenia, noting that more trials are necessary to verify its effectiveness.  However, the PORT recommendation is based on the opinions of clinicians rather than on empirical data, and empirical data exist that contradict this recommendation (link to abstract).  A review of current medical literature in The Cochrane Library, (the updated abstract of which is available online) reached the conclusion that no data exist that demonstrate that psychodynamic psychotherapy is effective in treating schizophrenia. Dr. Hyman Spotnitz and the practitioners of his theory known as Modern Psychoanalysis, a specific sub-specialty, still report (2007) much success in using their enhanced version of psychoanalytic technique in the treatment of schizophrenia.  Further data also suggest that psychoanalysis is not effective (and possibly even detrimental) in the treatment of sex offenders.

## Cost and length of treatment
The cost of psychoanalytic treatment ranges widely from city to city.  Low-fee analysis is often available in a psychoanalytic training clinic and graduate schools.  Otherwise, the fee set by each analyst varies with the analyst's training and experience.  Since, in most locations in the United States, unlike in Ontario and Germany, classical analysis (which usually requires sessions 3 to 5 times per week) is not covered by health insurance, many analysts may negotiate their fees with patients whom they feel they can help, but who have financial difficulties.
The various modifications of analysis, which include dynamic therapy, brief therapies, and certain types of group therapy (cf. Slavson, S. R., A Textbook in Analytic Group Therapy), are carried out on a less frequent basis - usually once, twice, or three times a week - and usually the patient sits facing the therapist.
Many studies have also been done on briefer "dynamic" treatments; these are more expedient to measure, and shed light on the therapeutic process to  some extent.  Brief Relational Therapy (BRT), Brief Psychodynamic Therapy (BPT), and Time-Limited Dynamic Therapy (TLDP) limit treatment to 20-30 sessions.  On average, classical analysis may last 5.7 years,  but for phobias and depressions uncomplicated by ego deficits or object relations deficits, analysis may run just a year or two.  Longer analyses are indicated for those with more serious disturbances in object relations, more symptoms, and more ingrained character pathology (such as obnoxiousness, severe passivity, or heinous procrastination).

## Curiosities, archaic ideas, and controversy
Freud revisited the Oedipal territory in the final essay of Totem and Taboo.  There, he combined one of Charles Darwin's more speculative theories about the arrangements of early human societies (a single alpha-male surrounded by a harem of females, similar to the arrangement of gorilla groupings) with the theory of the sacrifice ritual taken from William Robertson Smith.  Smith believed he had located the origins of  totemism in a singular event, whereby a band of prehistoric brothers expelled from the alpha-male group returned to kill their father, whom they both feared and respected. In this respect, Freud located the beginnings of the Oedipus complex at the origins of human society, and postulated that all religion was in effect an extended and collective solution to the problem of guilt and ambivalence relating to the killing of the father figure (which Freud saw as the true original sin).
In 1920, after the carnage of World War I, and after studying severe depressions and masochistic states, Freud became concerned with what today Parens has called "destructive aggression."  He began to formulate that there were wishes that drove human beings that were not sexual, but aggressive.  The concepts of a libidinal and an aggressive drive are still used clinically by a large number of practicing analysts, but there is today some dispute (and research into) the origins of either sexual or destructive fantasies and/or behavior.  Freud attempted, in "Beyond the Pleasure Principle" (1920), to theorize that there might be cellular origins to destructiveness, an idea that may be supported by current research into telomeres and cell death.  Most North American analysts, however, have not been persuaded by Freud's arguments that there is a "Death Drive" underlying aggression.  However, analysts in England (the Melanie Klein group) and South America utilize this concept.

## Cultural adaptations
Psychoanalysis can be adapted to different cultures, as long as the therapist or counseling understands the clients culture.  For example, Tori and Blimes found that defense mechanisms were valid in a normative sample of 2,624 Thais.  The use of certain defense mechanisms was related to cultural values.  For example Thais value calmness and collectiveness (because of Buddhist beliefs), so they were low on regressive emotionality.  Psychoanalysis also applies because Freud used techniques that allowed him to get the subjective perceptions of his patients.  He takes an objective approach by not facing his clients during his talk therapy sessions.  He met with his patients where ever they were, such as when he used free associationwhere clients would say whatever came to mind without self-censorship.  His treatments had little to no structure for most cultures, especially Asian cultures.  Therefore, it is more likely that Freudian constructs will be used in structured therapy (Thompson, et al., 2004).  In addition, Corey postulates that it will be necessary for a therapist to help clients develop a cultural identity as well as an ego identity.  Since Freud has been criticized for not accounting for external/societal forces, it seems logical that therapists or counselors using his premises will work with the family more.

### Play therapy, art therapy, and other therapies
Psychoanalytic constructs have been adapted and modified for use with children.  Play therapy, art therapy, and storytelling, have been the beneficiaries of these modifications.  Throughout her career, from the 1920s through the 1970s, Anna Freud (Sigmund Freud's daughter) adapted psychoanalysis for children through play.  This is still used today for children, especially those who are preadolescent (see Leon Hoffman, New York Psychoanalytic Institute Center for Children).  Using toys and games, children are able to demonstrate, symbolically, their fears, fantasies, and defenses;  although not identical, this technique, in children, is analogous to the aim of free association in adults.  Psychoanalytic play therapy allows the child and analyst to understand childrens' conflicts, particularly defenses such as disobedience and withdrawal, that have been guarding against various unpleasant feelings and hostile wishes.
Psychoanalytic constructs fit with constructs of other more structured therapies, and Firestone (2002) thinks psychotherapy should have more depth and involve both psychodynamic and cognitive-behavioral approaches.  For example, Corey states that Albert Ellis, the founder of Rational Emotive Behavioral Therapy (REBT), would allow his clients to experience depression over a loss, since such an emotion would be rationaloften people will be irrational and deny their feelings.
In art therapy, the counselor may have a child draw a portrait and then tell a story about the portrait.  The counselor watches for recurring themes  regardless of whether it is with art or toys.

# Criticisms
Psychoanalysis has been criticized on a variety of grounds by
- Mario Bunge
- Frank Cioffi
- Frederick Crews
- Hans Eysenck
- Ernest Gellner
- Adolf Grunbaum
- Han Israels
- Karl Kraus
- Jeffrey Masson
- Malcolm Bruce Macmillan
- Peter Medawar
- Karl Popper
- William Sargant
- Richard Webster
- Ludwig Wittgenstein
and others. Exchanges between critics and defenders of psychoanalysis have often been so heated that they have come to be characterized as the Freud Wars.
Popper argues that psychoanalysis is a pseudo-science because its claims are not testable and cannot be refuted, that is, they are not falsifiable. For example, if a client's reaction was not consistent with the psychosexual theory then an alternate explanation would be given (e.g. defense mechanisms, reaction formation).
Kraus was the subject of two books written by noted libertarian author Thomas Szasz. Karl Kraus and the Soul Doctors and Anti-Freud: Karl Kraus's Criticism of Psychoanalysis and Psychiatry portrayed Kraus as a harsh critic of Sigmund Freud and of psychoanalysis in general. Other commentators, such as Edward Timms (Karl Kraus - Apocalyptic Satirist) have argued that Kraus respected Freud, though with reservations about the application of some of his theories, and that his views were far less black-and-white than Szasz suggests.
Grunbaum argues that psychoanalytic based theories are falsifiable, and in fact are false. Other schools of psychology have produced alternative methods for psychotherapy, including behavior therapy, cognitive therapy, Gestalt therapy and person-centered psychotherapy.
Hans Eysenck determined that improvement was no greater than spontaneous remission. Between 2/3 and 3/4 of neurotics would recover naturally; this was no different from therapy clients. Prioleau, Murdock, Brody reviewed several therapy-outcome studies and
determined that psychotherapy is no different than placebo controls.
Michel Foucault, and similarly Gilles Deleuze, noted that the institution of psychoanalysis has become a center of power, with its confessional techniques being the same of the Christian tradition.
Due to the wide variety of psychoanalytic theories, varying schools of psychoanalysis often internally criticize each other. One consequence is that some critics offer criticism of specific ideas present only in one or more theories, rather than in all of psychoanalysis while not rejecting other premises of psychoanalysis. Defenders of psychoanalysis argue that many critics (such as feminist critics of Freud) have attempted to offer criticisms of psychoanalysis that were in fact only criticisms of specific ideas present only in one or more theories, rather than in all of psychoanalysis.  As the psychoanalytic researcher Drew Westen puts it, "Critics have typically focused on a version of psychoanalytic theorycirca 1920 at bestthat few contemporary analysts find compelling...In so doing, however, they have set the terms of the public debate and have led many analysts, I believe mistakenly, down an indefensible path of trying to defend a 75 to 100-year-old version of a theory and therapy that has changed substantially since Freud laid its foundations at the turn of the century." link to Westen article.

## Challenges to scientific validity
An early and important criticism of psychoanalysis was that its theories were based on little quantitative and experimental research, and instead relied almost exclusively on the clinical case study method.  In comparison, brief psychotherapy approaches such as behavior therapy and cognitive therapy have shown much more concern for empirical validation (Morley et al. 1999).  Some even accused Freud of fabrication, most famously in the case, and miraculous cure of Anna O. (Borch-Jacobsen 1996).
An increasing amount of empirical research from academic psychologists and psychiatrists has begun to address this criticism.
A survey of scientific research showed that while personality traits corresponding to Freud's oral, anal, Oedipal, and genital phases can be observed, they cannot be observed as stages in the development of children, nor can it be confirmed that such traits in adults result from childhood experiences (Fisher & Greenberg, 1977, p. 399). However, these stages should not be viewed as crucial to modern psychoanalysis. What is crucial to modern psychoanalytic theory and practice is the power of the unconscious and the transference phenomenon.
Some claim the idea of "unconscious" is contested because human behavior can be observed while human psychology has to be guessed at. However, the unconscious is now a hot topic of study at the undergraduate and graduate level in the fields of experimental and social psychology (e.g., implicit attitude measures, fMRI, and PET scans, and other indirect tests). One would be hard pressed to find scientists who still think of the mind as a "black box". Presently, the field of psychology has embraced the study of things outside one's awareness. Even strict behaviorists acknowledge that a vast amount of classical conditioning is unconscious and that this has profound effects on our emotional life. The idea of unconscious, and the transference phenomenon, have been widely researched and, it is claimed, validated in the fields of cognitive psychology and social psychology, though such claims are also contested. Recent developments in neuroscience have resulted in one side arguing that it has provided a biological basis for unconscious emotional processing in line with psychoanalytic theory, while the other side argues that such findings make psychoanalytic theory obsolete and irrelevant.
E. Fuller Torrey, considered by some to be a leading American psychiatrist, writing in Witchdoctors and Psychiatrists (1986) stated that psychoanalytic theories have no more scientific basis than the theories of traditional native healers, "witchdoctors" or modern "cult" alternatives such as est (p. 76). In fact, an increasing number of scientists regard psychoanalysis as a pseudoscience (Cioffi, 1998).
Among philosophers, Karl Popper argued that Freud's theory of the unconscious was not falsifiable and therefore not scientific. Popper did not object to the idea that some mental processes could be unconscious but to investigations of the mind that were not falsifiable.  In other words, if it were possible to connect every conceivable experimental outcome with Freud's theory of the unconscious mind, then no experiment could refute the theory.
Anthropologist Roy Wagner in his classic work The Invention of Culture ridicules psychoanalysis and tries to account for personality and emotional disorder in terms of invention and convention.
Some proponents of psychoanalysis suggest that its concepts and theories are more akin to those found in the humanities than those proper to the physical and biological/medical sciences, though Freud himself tried to base his clinical formulations on a hypothetical neurophysiology of energy transformations.  For example, the philosopher Paul Ricoeur argued that psychoanalysis can be considered a type of textual interpretation or hermeneutics.  Like cultural critics and literary scholars, Ricoeur contended, psychoanalysts spend their time interpreting the nuances of language  the language of their patients.  Ricoeur claimed that psychoanalysis emphasizes the polyvocal or many-voiced qualities of language, focusing on utterances that mean more than one thing.  Ricoeur classified psychoanalysis as a hermeneutics of suspicion.  By this he meant that psychoanalysis searches for deception in language, and thereby destabilizes our usual reliance on clear, obvious meanings.

## Theoretical criticism
Psychoanalysts have often complained about the significant lack of theoretical agreement among analysts of different schools.  Many authors have attempted to integrate the various theories, with limited success. However, with the publication of the Psychodynamic Diagnostic Manual much of this lack of cohesion has been resolved.
The philosopher Jacques Derrida incorporated certain aspects of psychoanalytic theory into his practice of deconstruction in order to question what he called the 'metaphysics of presence' or 'self-presence'. This was the defining trait (for Derrida) of traditional metaphysics, namely its assumption that the meaning of utterances can be pinned down and made fully evident to consciousness, perhaps most evident in Descartes' conception of 'clear and distinct ideas'. Derrida is here influenced by Freud (among others such as Marx and Nietzsche). For instance, Freud's insistence, in the first chapter of The Ego and the Id, that philosophers will recoil from his theory of the unconscious is clearly a forbearer to Derrida's understanding of metaphysical 'self-presence'. However, Derrida goes on to turn certain of these practices against Freud himself, in order (in Derrida's typical manner) to reveal tensions and contradictions in Freud's work which are nonetheless the very conditions upon which it can operate - its simultaneous conditions of possibility and impossibility. For instance, although Freud will define religion and metaphysics as a displacement of the identification with the father in the resolution of the Oedipal complex (e.g. in The Ego and The Id and Totem and Taboo) Derrida will insist (for instance in The Postcard) that the prominence of the father in Freud's own analysis is at the same time indebted to and an example of the prominence given to the father in Western metaphysics and theology since Plato. Thus (in a similar manner to that in which Levi-Strauss reads Freud's understanding of the Oedipal complex as but another version of the Oedipus myth), Derrida understands Freud as remaining partly within that theologico-metaphysical tradition ('phallologocentrism' Derrida helpfully calls it) which Freud nonetheless criticizes. However, the purpose of Derrida's analysis is not to refute Freud per se (which would only be to reaffirm traditional metaphysics), but rather to reveal an aporia (an undecidability) at the very heart of Freud's project. Such a 'deconstruction' (or indeed psychoanalysis) of Freud does tend to cast doubt upon the possibility of delimiting psychoanalysis as a rigorous science. However, in doing so it celebrates and pledges a critical allegiance to that side of Freud which emphasises the open-ended and improvisatory nature of psychoanalysis, and its (methodical and ethical) demand (for instance in the opening chapters of the Interpretation of Dreams) that the testimony of the analysand should be given prominence in the practice of analysis.
Psychoanalysis, or at least the dominant version of it, has been denounced as patriarchal or phallocentric by proponents of feminist theory. Other feminist scholars appreciate how Freud opened up society to female sexuality.

# List of psychoanalytical theorists
A few of the most influential psychoanalysts and theorists, philosophers and literary critics who were or are influenced by psychoanlaysis include:
- Nathan Ackerman - pioneer family therapist
- Alfred Adler- Proponent of individual psychology.
- Gerhard Adler
- Karl Abraham - Psychoanalyst.
- Nicholas Abraham - Psychoanalyst.
- Franz Alexander - Psychoanalyst.
- Lou Andreas-Salome - Psychoanalyst.
- Jacob Arlow
- Michael Balint
- Lee Baxandall
- Ernest Becker
- Therese Benedek
- John Benjamin
- Eric Berne - Proponent of transactional therapy.
- Bruno Bettelheim
- Edward Bibring
- Wilfred Bion
- John Bowlby
- Charles Brenner
- Abraham A. Brill
- Norman O. Brown
- Ruth Mack Brunswick
- Cornelius Castoriadis
- Janine Chasseguet-Smirgel - French psychoanalyst.
- Nancy Chodorow
- David Cooper
- Helene Deutsch
- Francoise Dolto
- Kurt R. Eissler
- Max Eitingen
- Erik Erikson
- Ronald Fairbairn
- Franklin Fearing
- Pierre Fedida
- Otto Fenichel
- Sandor Ferenczi
- J. C. Flugel
- S. H. Foulkes
- Anna Freud
- Sigmund Freud - Proponent of psychoanalysis.
- Erich Fromm - Social psychologist.
- Frieda Fromm-Reichmann
- Merton Gill
- Edward Glover
- Andre Green - Psychoanalyst.
- Ralph R. Greenson
- Felix Guattari- Philosopher.
- G. Stanley Hall - Psychologist.
- Heinz Hartmann - Psychiatrist and psychoanalyst.
- Paula Heimann
- James Hollis
- Karen Horney- Psychoanalyst.
- Luce Irigaray - Philosopher.
- Susan Sutherland Isaacs
- Edith Jacobson
- Ernest Jones
- Carl Jung - Psychoanalyst.
- Herman Hesse - Writer.
- Karl Kerenyi
- Otto Kernberg
- Paulina Kernberg
- Herbert Marcuse - Philosopher.
- Melanie Klein
- Heinz Kohut
- Julia Kristeva - Philosopher.
- Jacques Lacan
- R. D. Laing
- Jean Laplanche
- Jonathan Lear
- Bertram D. Lewin
- Hans Loewald
- Rudolf Loewenstein
- Margaret Mahler
- Maud Mannoni
- Adolf Meyer
- Donald Meltzer
- Karl Menninger
- Stephen A. Mitchell
- Juan-David Nasio
- Robert Neimeyer
- Erich Neumann
- Sandor Rado
- Otto Rank
- David Rapaport
- Wilhelm Reich - Psychoanalyst.
- Theodor Reik
- Joan Riviere
- Geza Roheim
- Herbert Rosenfeld
- Jurgen Ruesch
- Harold F Searles
- Hanna Segal
- Roy Schafer
- Melitta Schmideberg
- Sabina Spielrein
- Rene Spitz
- Hyman Spotnitz
- Daniel N. Stern
- Robert J Stoller
- Harry Stack Sullivan
- Viktor Tausk
- Maria Torok
- Frances Tustin- Psychoanalyst.
- Vamik Volkan - Psychiatrist.
- Donald Winnicott- Psychoanalyst.
- Gregory Zilboorg
- Slavoj Zizek - Philosopher.