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Various forms of psychotherapy predated psychoanalysis, but Sigmund Freud’s work offered a new form of therapeutic ‘talking cure’, which arguably shaped all subsequent forms of psychotherapy. Freud was a medically trained Viennese doctor who self-described as a neurologist. Freud encountered the idea of unconscious suggestion and psychotherapy through the work of his contemporary, Hyppolyte Bernheim, a French neurologist with an interest in the power of hypnotism. His curiosity for the subject was augmented by a study trip to the Parisian Salpêtrière hospital in 1895, under the mentorship of the celebrated neurologist Jean-Marie Charcot. Charcot was conducting research into a nervous illness associated with convulsions, emotional outbursts and odd or dramatic physical gestures, classed at the time as hysteria. He conducted experiments with hypnosis on hysteria patients, and claimed that the ability to be hypnotised was itself a symptom of hysteria. He believed there was a hereditary disposition towards susceptibility to hysteria, but challenged other doctors who saw it as a disease of the female reproductive system, arguing that it could also affect male patients who had undergone some form of trauma (Goldstein, 1987; Libbrecht and Quackelbeen, 1995). These cases enthralled the young Freud who, on this return to Vienna, began to elaborate on Charcot’s ideas. Inspired by the case of his friend Josef Breuer’s patient, Freud contended that hysteria was caused by underlying mental conflicts related to sexual trauma.

Psychoanalysis A form of long-term, one-to-one talking therapy developed by Sigmund Freud and his followers since the 1890s. It focuses on examining unconscious feelings, thoughts and desires, particularly through analysing transference.

Psychotherapy The use of a wide range of techniques, usually involving regular interpersonal meetings with a therapist, to work through emotional or behavioural difficulties in order to improve mental health or well-being.

In 1880 Breuer began treating Anna O (a pseudonym for Bertha Pappenheim), shown in Figure 3.1. Anna suffered from symptoms including paralysis, aphasia (loss of speech), amnesia and visual disturbances, and was eventually diagnosed with hysteria. During her consultations with Breuer, Anna O became preoccupied by reminiscences: discussing memories of significant relationships from her past, particularly her childhood, appeared to have a cathartic effect, and therefore a therapeutic benefit.

Figure 3.1 Anna O

Freud also became intrigued by Anna O’s expression of erotic feelings towards Breuer, which made Breuer highly uncomfortable. Freud posited that these desires were not in fact about Breuer specifically, but were redirected projections of impulses towards other significant people in her life. By analysing and interpreting this ‘transference’, as he came to call it, Freud suggested that patients might better understand and cope with their unconscious conflicts (Pick, 2015). This focus on transference was core to psychoanalytic theory and is the main feature distinguishing the so-called psychodynamic therapies (which adopt a more widespread and less intensive derivative of traditional psychoanalysis; the psychodynamic approach will be covered in Chapter 9). In 1896 Freud first used the term ‘psychoanalysis’ to distinguish this new approach from suggestion-based psychotherapies and went on to develop his thinking through a series of written case histories, which came to be known by their subjects: Little Hans, Dora, The Rat Man and The Wolf Man (Gay, 1988; Shamdasani, 2017).

Psychoanalytic theory A set of concepts and ideas underlying psychoanalytic practice, including theories about the structure of the conscious and unconscious mind, the emotional legacies of childhood relationships with parents, and sexual development.

Methodology: The ‘case study’ in the history of psychotherapy

Different traditions in psychotherapy have radically different philosophical underpinnings and divert from each other with regard to their norms of clinical practice. But if we look at them comparatively, the central role of the case study, or case history, is a striking continuity. Case histories are empirical records of research into the development of a person, usually in a real-life setting. This is one aspect that characterises psychotherapy as being different from experimental psychology, as the latter makes use of a very different type of evidence, which is reproducible through experiments.

The recording and publishing of case histories is not unique to psychotherapy, however, having been a common trope in medical writing for centuries. Just as in medicine, they provide a format for communicating clinical work to colleagues, and a textual basis for training new recruits to the profession. John Forrester pointed out the dual purpose of the case history for Freud and his followers: it served to show how people conform to common drivers and motivations, but ‘what many find most seductive in psychoanalysis is its promise to give an account of the divergences, the detours, the idiosyncrasies of the individual’s life’ (Forrester, 2017, p. 11). Freud wrote five long-form case studies in a literary style, which became an important part of the canon of psychoanalysis and laid out key theoretical concepts in context. Although case histories are still used in psychoanalysis, this long-form genre became less common after the theoretical concepts became accepted (Sealey, 2011).

Person-centred therapy also made use of large-scale analysis of multiple cases to find patterns that applied across all examples. From these, Carl Rogers abstracted six core concepts of ‘what it means to become a person’: the experience of feeling, the discovery of self in experience, openness to experience, trust in one’s organism, an internal locus of evaluation, and willingness to be a process (Rogers, 1967).

Rogers’ book Counselling and psychotherapy (1942) broke new ground as it contained a long transcript of the case of one client, Herbert Bryan, covering the eight sessions he had with Rogers. The recording of interviews became commonplace among the person-centred tradition and was seen to be important not only as a way of transmitting the approach to others, but also as a matter of transparency and external validation. By laying bare the full account of an interview, the reader could assess whether they agreed with Rogers’ approach and conclusions about the case (Raskin, 1996).

Cognitive and behavioural therapists also make use of case studies, for example by recording sessions for peer review and commentary. Unlike in the original psychoanalytic cases, where idiosyncrasy and diversions were a key feature, case studies are now sometimes presented as composites, partly because of modern concerns about confidentiality and to protect the identity of the individuals, but also because of the increasing focus on exemplary details rather than on individual stories in their own terms.

Initially, Freud thought hysteria patients were recapitulating memories of sexual abuse from childhood, which became known as his so-called ‘seduction theory’. He came to question this, however, and suspected that instead of memories, some of the unconscious material that was being presented may instead have been fantasy. This precipitated his invention of the Oedipus complex to denote the love-relationships and rivalries that young children struggle with in relation to their parents; expressions of infantile sexuality that would go on to shape relationships later in life. (His appropriation of Sophocles’ Oedipus Rex was one of many Classical references borrowed and refigured for explanatory purposes, and which added to the literary texture of his theories.) Freud also began to trace the stages of a child’s psychosexual development and claimed that the origins of anxieties in adult life had their roots in how these stages were negotiated in the person’s early years (Gay, 1988).

Oedipus complex A concept suggested by Freud describing a young child’s unconscious desire towards one of their (usually same-sex) parents and consequent feelings of rivalry and jealousy towards the other parent. Regarded as a key developmental stage.

Psychosexual development Freud’s framework for describing the development of a child’s sexuality in five stages as their sexual drives become associated with different body parts. The stages are: oral, anal, phallic, latency and genital.

If there is one aspect of psychotherapy that historians have attended to, it is psychoanalysis, and Freud himself in particular. Some, notably Carl Schorske, have pondered the particular reasons why such a concept of mind would emerge at that moment. Schorske situated Freud as part of an efflorescence of creative cultural production which broke away from the past towards a new modernist way of thinking that was less concerned with rationality and more with the emotional side of the psyche. While Freud was listening to the patients who lay on his therapy couch in Berggasse, literary figures such as Hugo von Hoffmannsthal and Arthur Schnitzler were frequenting nearby coffeehouses, along with revolutionary artists such as Gustav Klimt. At the turn of the century, Vienna was the cultural crucible in which a new, modern concept of ‘psychological man’ was forged (Schorske, 1980).

Others have focused more on continuities, showing how Freud’s ideas emerged from tropes that existed in nineteenth-century science, from evolutionary theory to German sexology (Makari, 2008; Sulloway, 1979). More critical historians have questioned the scientific credentials of Freud’s practice, characterising his interpretations of patients’ unconscious material as spurious. Such critics suggested that the relationship between the analyst and the patient was tainted by the power of suggestion, and drew attention to the careful ways in which Freud created psychoanalysis as a brand with its own centrally controlled training (Borch-Jacobsen and Shamdasani, 2012; Gellner, 1985).

Psychoanalysis quickly gained momentum, first at Freud’s own Wednesday evening meetings, beginning in 1902, which attracted visitors and trainee analysts from across Europe, including well-known names such as Carl Jung, Sabina Spielrein, Alfred Adler and Sandor Ferenczi. This was later formalised as the Vienna Psychoanalytic Society. A process of training, which required new analysts to undergo a personal analysis carried out by an existing psychoanalyst became the only route to legitimate practice. This resulted in a complex network of psychoanalysts linked to each other not only as colleagues with collegial relationships, but also through emotional and transferential relationships (Falzeder, 2015).

Despite his attempts to unify the movement, it was not long before personal splits and theoretical rifts also began to emerge among Freud’s early disciples. Jung was the first to break away in 1913, challenging Freud’s focus on sexuality and developing a theory of a shared collective unconscious. This theory drew on symbolic collective archetypes of myth and fairytale and had a heavier emphasis on cultural, spiritual and ancestral dimensions than Freud’s focus on the individual unconscious (Shamdasani, 2003). Jung’s ideas went on to inspire a range of psychotherapeutic approaches, from a Jungian school of analytic psychology through to artistic and creative therapies (Samuels, 1985). Alfred Adler also broke away, forming his own school of individual psychotherapy which, while it maintained a psychodynamic commitment to the idea of transference, overturned some Freudian motifs, notably abandoning Freud’s signature therapy couch in favour of two chairs (Ansbacher and Ansbacher, 1964).

Collective unconscious A concept suggested by Carl Jung to describe unconscious structures of the mind shared by all members of a species or group. These included instincts and universal symbols identified in myth and folklore, which he termed ‘archetypes’.

Freud’s influence continued to loom large, however, and informed a variety of innovations in psychiatric and psychotherapeutic thinking later in the twentieth century. Many analysts, including Freud himself, emigrated to western Europe and the Americas after Nazism swept across central Europe. They made significant contributions to the psychoanalytic societies that had already begun to emerge there. In London during the Second World War, vociferous debates about the nature of the child’s unconscious broke out between followers of Anna Freud and those of Melanie Klein respectively, with child analysis becoming an increasingly important practice in its own right (Zaretsky, 2005). The post-war period also became a time of experimentation with group analysis and saw the development of concepts about the nature of group dynamics and their implications for politics and society at the wider level (Bion, 2014). In the US, psychoanalysis became heavily integrated into the medical profession, and flourished in the post-war decades (Hale, 1995). More recently, historians have come to examine the misappropriation of psychoanalytic ideas, and sometimes even practice, for coercive political purposes during the cold war and under authoritarian regimes, reminding us of the potential that psychotherapy has for misuse (Damousi and Plotkin, 2012; Müller, 2016; ffytche and Pick, 2016).

To this day, on both sides of the Atlantic, Freudian and psychodynamic approaches based on ideas about transference and unconscious conflicts continue to inform psychotherapeutic training and practice, as well as wider culture and intellectual life, from film studies to literary theory. But from the mid-twentieth century, the psychoanalytic tradition was subject to fierce competition from two other key schools of psychotherapy: cognitive and behavioural therapies, and humanistic therapies.