The roots of psychodynamic thought and practice arguably were established in the office of the neurologist. By the late 19th century, European physicians were intrigued with the mystery of the many “hysterics” who came to see them. These hysterics were usually young women and they described assortments of symptoms including fainting, paralysis, and sensory disturbances.
Because of the centrality of neurological symptoms in their presentations, these patients often consulted neurologists, who were dismayed not only by the inexplicability of the symptoms, but by the often flighty and theatrical style of the sufferers. Clinicians were intrigued by the reported success achieved by Jean Martin Charcot and Hippolyte Bernheim, who were able to relieve hysterical symptoms using the recently disseminated technique of hypnosis. Bernheim, believing that hysteria was a product of suggestion, would implant posthypnotic suggestions that would reverse the symptoms of hysteria, if only temporarily. Among those who flocked to Bernheim’s clinic in 1888 was a Viennese neurologist, Sigmund Freud (1856-1939).

Born in a small town in the Austrian crown land of Moravia, Freud was the son of a lively wool merchant and his wife. The family moved to Vienna when Freud was about 5 years old. He was a brilliant student throughout his schooling, and a career in medicine was only natural for him. At the University of Vienna he worked in the laboratory of the renowned physiologist Ernst Brücke. In an era when the science of medicine was still tainted with remnants of folk wisdom and mystical philosophies, Brücke maintained that all forces in an organism could be reduced to the known physical and chemical ones. This notion of reductionism appealed to Freud, and he would spend much of his career trying to reduce psychological phenomena to their neurological bases, although he ultimately gave up that effort.

Freud’s particular interest was in neurophysiologic research, but opportunities in that field were scarce, so he entered the practice of clinical neurology. Brücke arranged for Freud to study both with Charcot in Paris and with Bernheim in Nancy. Returning to Vienna, he assisted Dr. Josef Breuer. One of Breuer’s patients displayed numerous symptoms of a hysterical nature, which emerged first when she was taking care of her dying father. Notably, she would also experience states she called “clouds,” which Breuer labeled as “spontaneous hypnosis.” In these states, she could relate her fantasies and often felt transiently better. When her recollections related her feelings to the meaning of a symptom, the relief was more sustained. Breuer and Freud hypothesized that every hysterical symptom has its origin in some psychologically traumatic event, and when the meaning of the symptoms is revealed, the patient loses the need to experience them.

This patient was identified as “Anna O.” when her case was featured in Studies in Hysteria by Freud and Breuer in 1895. She was overly fond of Breuer and developed a symptom of hysterical pregnancy, believing Breuer to be the father of her child. Breuer, a married man, abruptly ended her treatment and turned her care over to Freud. Freud took her further in her “chimney sweeping,” as she called the talking cure, and he discovered a wealth of sexual motivations underlying the hysterical processes.

As a footnote, Anna O., whose real name was Bertha Pappenheim, completed her treatment and became the first social worker in Germany and a vocal proponent of women’s suffrage. Freud subsequently took Bernheim’s technique a step further, discovering that if he allowed his patients to recall the events surrounding the origins of their hysterical symptoms under hypnosis, the symptoms would remit for much longer than with suggestion only, and sometimes permanently. Before long, Freud abandoned hypnosis altogether and encouraged patients simply to remember without censorship. Thus psychoanalysis was born.

Implicit in the cure of hysterics using recollection of forgotten experiences were two notions that formed the fundamental hypotheses of psychoanalysis:

The ability to assign meaning to the seemingly random symptoms of hysterics made psychic determinism an attractive hypothesis, since an object of science is to explain what seems inexplicable. The clinical cures (even if transient) that resulted from the communication of these meanings to the sufferers further bolstered the credibility of this notion. With enough mental effort and creativity, it is possible to assign meaning to all of our thoughts, feelings, behaviors, dreams, and mistakes.

To do so, however, often requires stretching the thread of motivation through territory that is inconsistent with conscious thought and recollection. The principle of psychic determinism thus necessitates the existence of a dynamic unconscious. If all our mental activity is linked to other mental processes, but we cannot see most of these links, then there must be a world of mental activity unavailable to the conscious mind. Although many of the specifics of Sigmund Freud’s derivations have been modified or challenged, these two fundamental principles remain at the bedrock of all psychodynamic theories. While Schopenhauer, Nietzsche, Goethe, Schiller, and others in the arts and sciences had acknowledged the existence of mental life beyond awareness, it was Freud who first gave it substantive recognition and described it in scientific detail. And since psychology at the end of the 19th century had already described much about memory, intellect, and other functions of the conscious mind, it would be in the realm of the unconscious that Freud and his followers would have the greatest contributions to make.

Freud first described three systems of awareness: conscious (system Cs), preconscious (system PCs), and unconscious (system UCs) reflecting, respectively, decreasing levels of immediate awareness. (See Table 1-1.)

These systems contain tempests of mental activity, so what is the source of energy for all this thinking and feeling? In Freud’s formulation, the energy springs from the drives. The drives are comparable to instincts in animals—biologically determined forces that promote the promulgation of the individual and the species. The term instinct, however, includes the behavior and motor activity resulting from the biological urge. In humans, the drives are only the sense of compulsion or urge toward some goal; the activity is separate. In his first formulation, Freud, consistent with the Darwinian paradigm of the times, postulated a sexual (reproductive) drive and a self-preservative drive. He soon dropped the latter and for the greater part of three decades elaborated his theories around a single sexual drive. This drive propels the human organism toward reproduction, connection, and afffection. By 1922, Freud was unable to explain the wealth of conflict and turmoil he observed in mental life on the basis of a single drive and postulated a second, the aggressive drive. This drive promotes destruction and disconnection.

The drives themselves are beyond conscious awareness, even though their names reflect conscious urges. They are biologically propelled urges. The aggression a person feels toward someone he or she hates, and the attraction he or she feels toward a love object, are drive manifestations or drive derivatives, but they are not the drives themselves.

In animals, instinct directs activity and every instinctual urge is either satisfied or given up. In people, the drives are purely mental entities. The pressure of a drive creates in the person a sense of excitation or tension. It is the natural state of the human animal to minimize this tension, and we do so either by direct gratification or by some other mode of accommodation. (We will see later in this chapter how these accommodations are managed.) Further, every thought, emotion, or fantasy embodies a mix of both sexual and aggressive drives. No love is without hostility or fear; no anger is without affection or envy. With just these simple principles in place, the mind is now a very active site: Sexual and aggressive
gressive drives coexist, often uncomfortably; if the drive impulse cannot be directly satisfied, the person is suspended in a state of tension and unfulfilled excitement; and this whole commotion is occurring outside the narrow bounds of conscious awareness.

The systems UCs, PCs, and Cs are the elements of the topographic model of the mind. By itself, the topographic description cannot portray how the drives operate and what directs movement among the topographic systems. It thus falls short of explanatory power to account for many of the ideas and symptoms of Freud’s analysands. This explanation is elucidated in Freud’s later structural model. The structures he defined are id, ego, and superego:

The mind of the newborn infant consists entirely of id. The child experiences pleasant and unpleasant physical sensations such as hunger and satiety, cold and warmth. He or she is driven toward gratification of id impulses, the earliest of which center on nursing and feeding. But the infant is completely at the mercy of his or her environment and can do nothing personally to gratify the urges. With maturation of the nervous system comes the ability to distinguish self from other, and the ability to manipulate parts of the self. So the child realizes that he or she can put his or her thumb into his or her mouth and at least partly gratify the urge to suck. Almost simultaneous is the pleasant sensation that the thumb has of being sucked, so the infant has become both the agent and the recipient of id gratification; this passage is the beginning of the ego. (In Freud’s words, “The ego is first a body ego.”)

Before long, the child acquires the ability to communicate, and the developing consciousness harbors the awareness that crying often produces relief. This ability will mature into the capacity for speech, just as motor skills develop to include the achievements of crawling and walking. Ego directs these abilities toward satisfaction of drive urges and minimization of discomfort.

Similarly, the growing brain acquires the capacity for memory. While the newborn is only aware of his or her mother when she is immediately in the child’s presence, the nine-month-old can remember that mother exists even when she is not there. Memory is the foundation for ego’s capacity for fantasy: When mother is not there, baby can imagine her presence and soothe himself or herself until mother really does arrive. In structural terms, this function is known as delayed gratification, an ego milestone. Ego is now able to serve id with mental tools in addition to motor skills.

Freud defined two types of mental function to describe the activities of the growing mind. Each refers both to a set of cognitive patterns, and to the ways in which drive energy is allocated and discharged: