Psychoanalysis: Freud’s Approach to Therapy

Psychoanalytic therapy aims to create the right sort of conditions so that the patient can bring these conflicts into the conscious mind, where they can be addressed and dealt with. 

Only by having a cathartic (i.e., healing) experience is the person helped and “cured.”

How Can We Understand The Unconscious Mind?

Remember, psychoanalysis is a therapy as well as a theory. Psychoanalysis is commonly used to treat depression and anxiety disorders.

In psychoanalysis, Freud would have a patient lie on a couch to relax. He sat behind them, taking notes, while they talked about their dreams and childhood memories.

Psychoanalysis would be a lengthy process, involving many sessions with the psychoanalyst.

The Process of Psychoanalysis

During psychoanalysis, the analyst interprets the patient’s thoughts, actions, dreams, and defenses, helping them uncover unconscious conflicts that influence behavior.

The analyst often waits until the patient is on the verge of reaching an insight themselves before offering an interpretation. This timing maximizes its emotional and therapeutic impact.

A frequent challenge in analysis is denial, when a patient rejects an interpretation that threatens their ego.

Analysts may view this denial as a further form of defensive behavior. It reveals the patient’s resistance, the unconscious avoidance of painful material, such as changing the subject or arriving late, which psychoanalysis treats as itself clinically significant.

That’s the clinical logic.

Modern psychoanalysts, often called ego analysts, place greater emphasis on the ego’s role than Freud originally did (Davison & Neale, 1994).

Ego strength matters. They argue that defense mechanisms serve as the ego’s unconscious tools for protecting the individual from anxiety and internal conflict.

Resistance, Insight, and Technique

Because defense mechanisms and unconscious processes are difficult to access, classical psychoanalysis is typically a lengthy process, often requiring two to five sessions per week over several years.

Resistance is a key focus of analysis.

Patients may unconsciously resist confronting painful material, by changing the topic, missing appointments, or avoiding discussion of certain themes.

Freud regarded such resistances as valuable clues, revealing areas of deep unconscious conflict.

Reducing surface symptoms is not enough. Unless the underlying conflict is resolved, new neurotic symptoms are likely to take their place.

The analyst deliberately remains a blank screen, revealing little about themselves. This lets the patient’s unconscious thoughts and feelings, especially transference, the unconscious redirecting of feelings (often about parents) onto the therapist, emerge freely.

Common techniques include:

• Free association – encouraging spontaneous verbalization of thoughts.

• Dream analysis – interpreting latent meanings of dreams.

• Resistance analysis – identifying and understanding forms of avoidance.

• Transference analysis – examining how feelings toward significant others are projected onto the analyst.

• Projective techniques such as inkblot tests and parapraxes (Freudian slips), which reveal unconscious material indirectly.

Together, these methods aim to bring unconscious conflicts into conscious awareness, allowing the individual to achieve insight, integration, and psychological growth.

1) Rorschach inkblots

Due to the nature of defense mechanisms and the inaccessibility of the deterministic forces operating in the unconscious,

The Rorschach inkblot itself doesn”t mean anything, it’s ambiguous (i.e., unclear). It is what you read into it that is important. Different people will see different things depending on what unconscious connections they make.

The inkblot is known as a projective test as the patient “projects” information from their unconscious mind to interpret the inkblot.

However, behavioral psychologists such as B.F. Skinner have criticized this method as being subjective and unscientific.

2) Freudian Slip

Unconscious thoughts and feelings can transfer to the conscious mind in the form of parapraxes, popularly known as Freudian slips or slips of the tongue.

We reveal what is really on our mind by saying something we didn’t mean to.

Freud took this seriously.

Freud believed that these were no accidents but were due entirely to the workings of the unconscious. As such, they were a valuable source of insight into this part of the human mind.

These are more technically known as parapraxes.

For example, a nutritionist giving a lecture intended to say we should always demand the best in bread, but instead said bed. Another example is where a person may call a friend’s new partner by the name of a previous one, whom we liked better.

The slip still counts.

Freud believed that slips of the tongue provided insight into the unconscious mind and that there were no accidents. Every behavior, including a slip of the tongue, was significant: all behavior is determined.

3) Free Association

A key part of learning to conduct psychoanalytic psychotherapy involves developing skills and techniques aimed at accessing and understanding unconscious processes.

This includes facilitating the client’s free association, where the client expresses whatever thoughts or feelings come to mind without censorship.

As unconscious ideas and emotions emerge, the therapist helps the client explore and make meaning of them.

Free association is a psychoanalytic term used to describe the free association of ideas that can give an insight into the unconscious mind of the patient.

In free association, the patient is encouraged to speak freely and to verbalize anything that comes to mind. In this way the patient may be able to bring content to the surface that has previously been censored by the ego.

This technique involves a therapist giving a word or idea, and the patient immediately responds in an unconstrained way with the first word that comes to mind. The analyst then offers an interpretation of the relationship observed.

It is hoped that fragments of repressed memories will emerge in the course of free association, giving an insight into the unconscious mind.

Resistance, Abreaction, and Catharsis

Free association can sometimes be met with resistance – moments when the client hesitates, changes the subject, or refuses to elaborate.

Freud viewed such resistance as a valuable clue that the client was approaching repressed or emotionally charged material.

At times, free association may evoke vivid, emotionally intense recollections in which the client relives a past trauma, a process Freud described as abreaction.

When such emotional release leads to a sense of relief or inner cleansing, it is referred to as catharsis.

Freud found that these deeply emotional experiences often provided powerful insight into the client’s unconscious conflicts, helping them integrate repressed material and move toward greater psychological understanding.

4) Dream Analysis

Freud famously described dream analysis as “the royal road to the unconscious.”

The dream’s surface story is rarely the whole story.

He proposed that the conscious mind acts as a censor, filtering and disguising unacceptable thoughts and desires, yet this censorship weakens during sleep.

Dreams, therefore, offer a unique window into the unconscious mind, allowing repressed thoughts and emotions to surface in symbolic form.

The disguise is the point.

The analyst’s role is to help the patient unravel these symbols and uncover the hidden meanings behind them.

According to Freud, dreams often disguise the dreamer’s true concerns to protect the conscious mind from anxiety or guilt.

Rather than dreaming directly about a distressing issue, the dreamer might instead dream about something that represents it symbolically.

Manifest and Latent Content

Freud distinguished between two levels of dream content:

• Manifest content – the literal storyline or imagery of the dream (what the dreamer consciously remembers).

• Latent content – the hidden psychological meaning of the dream, representing the repressed wishes or conflicts that the manifest content disguises.

Through the process of dream interpretation, the analyst works to decode the latent meaning, revealing the unconscious wishes and motives shaping the patient’s emotional life.

Freud also suggested that many dreams carry sexual symbolism, reflecting the central role of instinctual drives in the psyche.

In his theory of sexual symbolism, he speculated that seemingly ordinary dream elements often represent deeper, unconscious desires.

Dream analysis thus remains one of the most distinctive and enduring features of psychoanalytic therapy, providing a bridge between the hidden world of the unconscious and the conscious self.

5) Transference Analysis

Transference refers to how the client relates to the therapist in ways that unconsciously reflect early important relationships.

Of key importance in psychoanalytic therapy is transference. Freud had originally noticed that his patients sometimes felt and acted toward him as if he were an important person from the patient’s past.

Sometimes, these feelings were positive, but sometimes they were negative and hostile. Freud assumed these were relics of attitudes held toward these important persons in the patient’s past.

Freud felt that this transference was an inevitable aspect of psychoanalysis, and used it to explain to patients the childhood origins of many of the concerns and fears.

In psychoanalysis, transference is seen as essential to a complete cure. Analysts use the fact that transference is developing as a sign that an important repressed conflict is nearing the surface.

Countertransference

The therapist’s own unconscious reactions to the client that can give insight into the therapeutic relationship dynamics.

In psychoanalysis, countertransference refers to the emotional reactions and unconscious biases a therapist might have towards a patient, often influenced by the therapist’s own past experiences or unresolved feelings.

It’s the therapist’s emotional response to the patient’s transference.

So, trainees learn to attend carefully to the emotional interchanges within the therapy relationship as a source of insight into both parties’ unconscious relational patterns stemming from their developmental histories.

Clinical Applications

Psychoanalysis, along with Rogerian humanistic counseling, is a global therapy. Its aim is to help clients change their whole perspective on life, not just relieve one symptom.

That is the whole point.

This approach assumes that maladaptive ways of thinking and behaving stem from unresolved, deep-seated personality conflicts rooted in early experiences.

Global therapies like psychoanalysis differ from problem-based therapies (e.g., cognitive-behavioral therapy) that primarily aim to reduce or manage symptoms rather than explore their origins.

Psychoanalysis has traditionally been applied to neurotic disorders—such as anxiety, depression, and certain eating disorders—rather than psychotic conditions like schizophrenia.

Depression is a harder case.

Its success with depression has been debated, since the inactivity and apathy often associated with depressive states can make sustained engagement with therapy difficult.

Depressive clients are also particularly prone to transference, developing deep dependency on their therapist, which can complicate the therapeutic process (Comer, 1995).

Effectiveness and Treatment Considerations

Psychoanalytic therapy has been used to treat anxiety-related disorders, including phobias, panic attacks, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

The central aim is to help clients recognize how their unconscious conflicts and early childhood relationships contribute to their present-day anxiety, enabling them to integrate these experiences and reduce symptoms.

However, empirical findings on its effectiveness remain mixed and context-dependent.

• Svartberg and Stiles (1991) and Prochaska and DiClemente (1984) report that evidence for psychoanalysis is equivocal.

• Salzman (1980) suggests that psychodynamic therapies are less helpful for specific anxiety disorders (e.g., OCD or phobias), but may benefit clients with generalized anxiety disorder (GAD).

• Some studies even warn that psychoanalysis might worsen symptoms in individuals with OCD due to their tendency to overanalyze thoughts and behaviors (Noonan, 1971).

In the treatment of depression, psychoanalysts often trace the condition to early experiences of loss, particularly the child’s realization of separateness from the caregiver.

Failure to process this early separation may lead to vulnerability to depression later in life.

Therapy involves revisiting these early experiences.

That work is called working through: the gradual, repeated process of re-examining a conflict across many sessions, addressing fixations and maladaptive coping mechanisms along the way.

Particular care must be taken with transference, as depressed individuals often develop strong dependency needs.

The goal is to help clients develop autonomy, accept loss, and adapt to change in healthier ways.

Progress is often slow.

Still, Shapiro and Emde (1991) note that psychodynamic therapies have achieved only occasional success, partly because some depressive clients lack the motivation to engage actively in long-term analysis.

Others may expect quick results, which psychoanalysis—being a gradual, exploratory process—cannot provide.

Critical Evaluation

Practical Limitations and Ethical Concerns

Psychoanalysis is time-consuming, intensive, and costly, often requiring years of treatment and multiple sessions per week.

Clients must be highly motivated and emotionally prepared to engage with potentially painful repressed memories that surface during therapy.

Because the process can evoke distress before progress occurs, psychoanalysis is not suitable for all individuals or disorders.

Moreover, the inherently unequal power dynamic between therapist and client raises ethical questions, particularly around dependency and transference.

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Who Benefits Most?

Critics argue that psychoanalysis primarily benefits a narrow demographic.

The acronym YAVIS – standing for Young, Attractive, Verbal, Intelligent, and Successful – is often used to describe the clients most likely to benefit from this form of therapy.

While few studies confirm all these traits, there is consistent evidence that psychoanalysis is most effective for clients who are highly motivated, self-aware, and open to introspection.

Those seeking rapid relief or struggling with severe mental illness may not find it suitable.

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Effectiveness and Conflicting Evidence

The effectiveness of psychoanalysis has long been debated.

Eysenck (1952) delivered one of the harshest critiques. He claimed that roughly half of neurotic patients recovered within two years, while two-thirds of untreated patients improved without any therapy at all.

However, later analyses challenged Eysenck’s conclusions.

Bergin (1971) found that, using different outcome criteria, 83% of psychoanalytically treated clients showed improvement. Bergin and Lambert (1978) later put the untreated spontaneous-remission rate nearer 43%, still well below the treated group’s rate.

The comparison numbers vary by source.

Similarly, Fisher and Greenberg (1977) concluded that psychoanalytic theory should not be accepted or rejected as a whole. Some components, they argued, are empirically supported, while others require revision or reinterpretation.

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Contemporary Research

A 2015 UK trial tested whether adding long-term psychoanalytic therapy to usual care helped patients whose depression had already resisted other treatments.

Aim: To test whether long-term psychoanalytic psychotherapy added to usual NHS care improves outcomes for treatment-resistant depression (Fonagy et al., 2015).

Method: 129 patients with chronic, treatment-resistant depression were randomly allocated to eighteen months of weekly psychoanalytic therapy plus usual care, or to usual care alone. They were followed for 42 months.

Results: Full remission stayed rare in both groups, but the psychoanalytic group showed a steadily widening rate of partial remission, reaching 34.7% versus 4.4% by 42 months.

Conclusion: The benefit grew over time instead of fading. This suggests psychoanalytic therapy can still help patients for whom brief, symptom-focused treatments have already failed.

A larger synthesis points the same way. Steinert and colleagues (2017) pooled a substantial literature of randomised controlled trials and found psychodynamic therapy statistically equivalent to established treatments such as CBT.

Together, these findings update the older picture of psychoanalysis rather than overturning it. It still moves more slowly than brief therapies for some problems, but its effects tend to hold, and even grow, well after treatment ends.

Methodological Challenges

Evaluating psychoanalysis is notoriously difficult due to individual differences between clients and therapists, as well as the subjective nature of change.

Unlike behavioral therapies, which can measure outcomes through observable symptom reduction, psychoanalysis often aims for deep personality restructuring, which is harder to quantify.

Corsini and Wedding (1995, 2013) estimate cure rates between 30% and 60%, depending on how “improvement” is defined.

Additionally, the case study method—central to Freud’s work—has been criticized for lacking objectivity and generalizability.

Famous cases like Little Hans provide valuable insights but are open to observer bias and cannot establish universal principles.

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Science and Subjectivity

Attempts to validate Freud’s theory through experimental methods have also been questioned.

Fonagy (1981) argues that such efforts may miss the point entirely. Freud’s framework, on this view, is itself a critique of scientific rationalism, not a theory meant to conform to it.

That reframing matters.

Psychoanalysis, therefore, may occupy a unique position—straddling the line between clinical art and psychological science.

While its subjective nature limits scientific validation, it continues to offer profound insights into human motivation, emotion, and interpersonal dynamics.

As Anthony Storr (1987) observed, many psychoanalysts draw from rich clinical experience, but these interpretations are inevitably shaped by personal bias and theoretical orientation, making psychoanalysis more interpretive than empirical.

Neo Freudians

Subsequent psychoanalytic theorists built upon but also challenged Freud’s drive theory.

Freud was not the last word.

Object relations theory shifted focus to relationships and attachment, with key figures like Melanie Klein, Donald Winnicott, and John Bowlby.

They emphasized how internal working models of self/other, based on early caretaker relationships, shape personality and relational patterns.

Harry Stack Sullivan and interpersonal psychoanalysis highlighted social and cultural factors influencing mental health.

Kohut looked elsewhere.

Heinz Kohut’s self-psychology focused on empathy, attunement, and disorders of the self like narcissism.

Intersubjective and relational psychoanalysis theories view the client’s and therapist’s subjectivities as co-created in an intersubjective field, with attention to enactments and dissociated self states, especially for trauma survivors.

Attachment Theory vs Psychoanalysis

Attachment theory, developed by John Bowlby, and psychoanalytic theory, developed by Sigmund Freud, offer complementary perspectives on human development and relationships.

While attachment theory reacted against some psychoanalytic views, like drive theory, the two approaches converge on many topics.

Both see early childhood experiences as shaping internal models that influence adult relationships and behavior.

The overlap is real.

Attachment research provides empirical evidence that unresolved issues from childhood perpetuate across generations, a key psychoanalytic claim.

Concepts like internal working models and secure base align with psychoanalytic ideas like transference and the therapeutic relationship fostering insight.

However, attachment theory more strongly emphasizes the impact of actual childhood events, whereas psychoanalysis highlights inner reality and fantasy.

Neither view fully replaces the other.

Both offer useful frameworks for understanding how relational patterns persist or change across the lifespan.

Their differences can spark productive dialogue on the roles of inner and outer reality in development.

Training

Psychoanalytic education also involves the trainee undergoing extensive personal therapy.

Experiencing the therapy process directly gives them firsthand insight into their own psychological conflicts, attachment history, unconscious reactions, and clinical blind spots.

This helps develop self-awareness and attunement needed to understand and respond helpfully to clients’ unconscious communications.

That reflection is not optional.

Cultural competence requires analysts to engage in ongoing self-examination around differences and power dynamics related to their own and their clients’ sociocultural identities and experiences.

Unconscious assumptions, biases, stereotypes etc. rooted in culture and privilege/oppression influence clinical perceptions and relationships, so their ongoing reflection upon is considered imperative.

The multiple layers of self-exploration around unconscious processes in one’s personal therapy, clinical work, supervision, and sociocultural context form the bedrock of psychoanalytic clinical education and skill development.

Learning Check: You are the Therapist