Psychoanalysis

In "On Beginning the Treatment" (1913), in explaining the method of free association, a hallmark of psychoanalytic technique, Freud likened it to a train journey. "Act as though, for instance, you were a traveler sitting next to the window of a railway carriage and describing to someone inside the carriage the changing views which you see outside" (Freud, vol. 12, p. 135). The "landscape" thus revealed was that of the patient's own inner world, its features psychic conflicts; at the heart of the psychoanalytic method is the proposition that interpretation of unconscious conflicts, and the subsequent insight gained by the patient, are themselves mutations of those conflicts. The patient's fantasies and unconscious desires are thrown upon the person of the analyst, through a phenomenon known as transference. Transference, literally the unconscious carrying over into the present of the meaningful relationships of the past, and of the fantasies and repressed wishes that shaped them, is at the core of all kinds of analytic therapy.

But in clinical work, especially with more disturbed patients, many therapists of the early twenty-first century embrace the value of a "therapeutic object," and indeed believe that this kind of work is essential to any kind of therapeutic progress with such patients. The idea of the therapeutic object is related to British analyst D. W. Winnicott's notion of the holding environment and to analytic empathy, an idea especially prominent in Heinz Kohut's work with narcissistic patients. Both these writers assumed that an infant's development is inescapably bound to her relations with her first caregivers, and that the emergence of the subjective, intrapsychic world coincides with the development of the infant's relations with these early objects. They presume, in different ways, that pathology, particularly more disturbed pathology, results from disturbances in this process, and that it is among the tasks of psychodynamic therapy to supplement the patient's earliest, often deforming, object relationships with newer healthy models, which can be internalized over time. According to this view, by revisiting and remodeling the earliest patterns of relating to the world (through internalization of new objects), lasting change may be effected both in the patient's internal world and in her relationships with new objects in the present.

This point of view is not shared by all contemporary analysts, least of all those "classical" analysts, who maintain that psychopathology is by and large derived from Oedipal and post-Oedipal development, that is, the point at which a patient begins to make symbolic sense of inner impulses and distorts them according to the repression. The classical view tends to play down or deny the importance of structural, ego "deficits" in early (pre-Oedipal) development resulting from inadequate nurture.