Freud’s starting point⁽⁴⁾ was his study of hysterical patients and the discovery that, when he found a way to help these patients piece together a coherent account of the antecedents of their conversion symptoms, dissociative phenomena, and pathological affective dispositions, all these psychopathological phenomena could be traced to traumatic experiences in their past that had become unconscious. That is, these traumatic experiences continued to influence the patients’ functioning despite an active defensive mechanism of ‘repression’ that excluded them from the patient’s conscious awareness. In the course of a few years, Freud abandoned his early efforts to recover repressed material by means of hypnosis, and replaced hypnosis with the technique of ‘free association’, an essential aspect of psychoanalytic technique until the present time. Freud instructed his patients to eliminate as much as possible all ‘prepared agendas’, and to try to express whatever came to mind, while attempting to exert as little censorship over this material as they could. He provided them with a non-judgemental and stable setting in which to carry out their task, inviting them to recline on a couch while he sat behind it. The sessions lasted for an hour and were conducted five to six times a week. There has been little change in the essentials of this format, except that sessions have been shortened to 45 to 50 min and are carried out three to
five times a week. The method of free association led to the gradual recovery of repressed memories of traumatic events. Originally, Freud thought that the recovery of such events into consciousness would permit their abreaction and elaboration, and thus resolve the patients’ symptoms.

Practicing this method led Freud to several lines of discovery. To begin, he conceptualized unconscious mechanisms of defence that opposed the recovery of memories by free association. He described these mechanisms, namely, repression, negation, isolation, projection, introjection, transformation into the opposite, rationalization, intellectualization, and most important, reaction formation. The last of these involves overt chronic patterns of thought and behaviour that serve to disguise and disavow opposite tendencies linked to unconscious traumatic events and the intrapsychic conflicts derived from them. The discovery of reaction formations led Freud to the psychoanalytic study of character pathology and normal character formation, and still constitutes an important aspect of the contemporary psychoanalytic understanding and treatment of personality disorders (for practical purposes, character pathology and personality disorders are synonymous concepts).

A related line of development in Freud’s theories was the discovery of the differential characteristics of conscious and unconscious thinking. Freud differentiated conscious thinking, the ‘secondary process’, invested by ‘attention cathexis’ and dominated by sensory perception and ordinary logic in relating to the psychosocial environment, from the ‘primary process’ of the ‘dynamic unconscious’. That part of the unconscious mind he referred to as ‘dynamic’ exerted constant pressure or influence on conscious processes, against the active barrier constituted by the various defensive operations, particularly repression. The dynamic unconscious, Freud proposed, presented a general mobility of affective investments, and was ruled by the ‘pleasure principle’ in contrast to the ‘reality principle’ of consciousness. The ‘primary process’ thinking of the dynamic unconscious was characterized by the absence of the principle of contradiction and of ordinary logical thinking, the absence of negation and of the ordinary sense of time and space, the treatment of a part as if it were equivalent to the whole, and a general tendency towards condensation of thoughts and the displacement of affective investments from one to another mental content.

Finally, Freud proposed a ‘preconscious’, an intermediate zone between the dynamic unconscious and consciousness. It represented the storehouse for retrievable memories and knowledge and for affective investments in general, and it was the seat of daydreaming, in which the reality principle of consciousness was loosened, and derivatives of the dynamic unconscious might emerge. Free association, in fact, primarily tapped the preconscious as well as the layer of unconscious defensive operations opposing the emergence of material from the dynamic unconscious.

This model of the mind as a ‘place’ with unconscious, preconscious, and conscious ‘regions’ constituted Freud’s⁽¹⁾ ‘topographic theory’. He eventually replaced it with the ‘structural theory’ namely, the concept of three interacting psychic structures, the ego, the superego, and the id.⁽⁵⁾ This tripartite structural theory is still the model of the mind that dominates psychoanalytic thinking. A major determinant of the shift from the topographic to the structural model was Freud’s recognition that the ‘regions’ of conscious, preconscious, and unconscious were fluid, and that the defence mechanisms directed against the emergence in consciousness of the dynamic unconscious were themselves unconscious. Another consideration was Freud’s⁽⁶⁾ discovery of a specialized unconscious system of infantile morality, the superego. What follows is a summary of the characteristics and contents of these structures, an analysis that will lead us directly into contemporary psychoanalytic formulations.

The id is the mental structure that contains the mental representatives of the ‘drives’, that is, the ultimate intrapsychic motivations that Freud⁽⁷⁾ described in his final, ‘dual-drive theory’ of libido and aggression, or metaphorically, the sexual or life drive and the destruction or death drive to be examined below. Behind this categorical formulation lies a complex set of discoveries regarding the patients’ unconscious experiences that Freud came across in the course of the application of the psychoanalytic method to the treatment of neurotic and characterological symptoms. In exploring unconscious mental processes, what at first appeared to be specific traumatic life experiences turned out to reflect surprisingly consistent, repetitive intrapsychic experiences of a sexual and aggressive nature.

Freud⁽⁴⁾ was particularly impressed by the regularity with which his patients reported the emergence of childhood memories reflecting seductive and traumatic sexual experiences on one hand, and intense sexual desires and related guilt feelings, on the other. He discovered a continuity between the earliest wishes for dependency and being taken care of (the psychology, as he saw it, of the baby at the mother’s breast) during what he described as the ‘oral phase’ of development; the pleasure in exercising control and struggles around autonomy in the subsequent ‘anal phase’ of development (the psychology of toilet training); and, particularly, the sexual desire towards the parent of the opposite gender and the ambivalent rivalry for that parent’s exclusive love with the parent of the same gender. He described this latter state as characteristic of the ‘infantile genital stage’ (from the third or fourth to the sixth year of life) and called its characteristic constellation of wishes and conflicts the positive Oedipus complex. He differentiated it from the negative Oedipus complex, i.e. the love for the parent of the same gender, and the corresponding ambivalent rivalry with the parent of the other gender. Freud proposed that Oedipal wishes came to dominate the infantile hierarchy of oral and anal wishes, becoming the fundamental unconscious realm of desire.

Powerful fears motivated the repression of awareness of infantile desire: the fear of loss of the object, and later of the loss of the object’s love was the basic fear of the oral phase, directed against libidinal wishes to possess the breast; the fear of destructive control and annihilation of the self or the object was the dominant fear of the anal phase directed against libidinal wishes of anal expulsion and retentiveness, and the fear of castration, ‘castration anxiety’, the dominant fear of the Oedipal phase of development, directed against libidinal desire of the Oedipal object. Unconscious guilt was a dominant later fear, originating in the superego and generally directed against drive gratification (see under superego). Unconscious guilt over sexual impulses unconsciously equated with Oedipal desires constitute a major source of many types of pathology, such as sexual inhibition and related character pathology.

Prototypical intrapsychic infantile experiences linked to the Oedipus complex were fantasies and perceptions around the sexual intimacy of the parents (the ‘primal scene’), and unconscious fantasies derived from experiences with primary caregivers (‘primal seduction’). In all these phases of infantile development of drive motivated wishes and fears, powerful aggressive strivings accompanied the libidinal ones, such as cannibalistic impulses during the oral phase of physical dependency on the breast and psychological dependency on mother, sadistic fantasies linked to the anal phase, and parricidal wishes and phantasies in the Oedipal stage of development.

Freud described the oral phase as essentially coinciding with the infantile stage of breast feeding, the anal phase as coinciding with struggles around sphincter control, and the Oedipal stage as developing gradually during the second and through the fourth years, and culminating in the fourth and the fifth years of life. This latter phase would then be followed by more general repressive processes under the dominance of the installation of the superego, leading to a ‘latency phase’ roughly corresponding to the school years, and finally, to a transitory reactivation of all unconscious childhood conflicts under the dominance of Oedipal issues during puberty and early adolescence.

The drives represent for human behaviour what the instincts constitute for the animal kingdom, i.e. the ultimate biological motivational system. The drives are constant, highly individualized, developmentally shaped motivational systems. Under the dominance of the drives and guided by the primary process, the id exerts an ongoing pressure towards gratification, operating in accordance with the pleasure principle. Freud initially equated the drives with primitive affects. After discarding various other models of unconscious motivation, he ended up with the dual-drive theory of libido and aggression.

He described the libido or the sexual drive as having an ‘origin’ in the erotogenic nature of the leading oral, anal, and genital bodily zones; an ‘impulse’ expressing the quantitative intensity of the drive by the intensity of the corresponding affects; an ‘aim’ reflected in the particular act of concrete gratification of the drive; and an ‘object’ consisting of displacements from the dominant parental objects of desire.

The introduction of the idea of an aggressive or ‘death’ drive, arrived at later in Freud’s^{(7, 8)} writing, stemmed from his observations of the profound self-destructive urges particularly manifest in the psychopathology of major depression and suicide, and of the ‘repetition compulsion’ of impulse-driven behaviour that frequently seemed to run counter to the pleasure principle that supposedly governed unconscious drives. He never spelled out the details of the aggressive drive as to its origins. This issue was taken up later by Klein,⁽⁹⁾ Fairbairn,⁽¹⁰⁾ Winnicott,⁽¹¹⁾ Jacobson,⁽¹²⁾ and Mahler and her colleagues.⁽¹³⁾ Freud described drives as intermediate between the body and the mind; the only thing we knew about them, Freud suggested,⁽¹⁴⁾ were ‘representations and affects’.

The psychoanalytic theory of psychopathology proposes that the clinical manifestations of the symptomatic neuroses, character pathology, perversions, sexual inhibitions, and selected types of psychosomatic and psychotic illness reflect unconscious intrapsychic conflicts between drive derivatives following the pleasure principle,
defensive operations reflecting the reality principle, and the unconscious motivations of the superego. Unconscious conflicts between impulse and defence are expressed in the form of structured conflicts between the agencies of the tripartite structure: there are ego defences against impulses of the id; the superego motivates inhibitions and restrictions in the ego; at times the repetitive, dissociated expression of id impulses (‘repetition compulsion’) constitutes an effective id defence against superego pressures. The resolution of unconscious conflicts implies the analysis of all these intersystemic conflicts.

All these conflicts are expressed clinically by three types of phenomena:

1 inhibitions of normal ego functions regarding sexuality, intimacy, social relations, work, and affect activation;

2 compromise formations between repressed impulses and the defences directed against them;

3 dissociative expression of impulse and defence.

The last category implies a dominance of the splitting mechanisms referred to before; these have acquired central importance in the understanding of severe character pathology as reflected in contemporary psychoanalytic thinking.

Psychoanalytic treatment consists, in essence, in facilitating the reactivation of the pathogenic unconscious conflicts in the treatment situation by means of a systematic analysis of the defensive operations directed against them. This leads to the gradual emergence of repressed impulses, with the possibility of elaborating them in relation to the analyst, and their eventual adaptive integration into the adult ego. Freud⁽²⁵⁾ had described the concept of ‘sublimation’ as an adaptive transformation of unconscious drives: drive derivatives, converted into a consciously tolerable form, are permitted gratification in a symbolic way while their origin remains unconscious. The result of this process is an adaptive, non-defensive compromise formation between impulse and defence. In analysis, the gradual integration into the patient’s conscious ego of unconscious wishes and desires from the past and the understanding of the phantasized threats and dangers connected with them, facilitates their gradual elaboration and sublimatory expression in the consulting room and in everyday life as well.

In the light of contemporary object-relations theory, the formulation based upon the structural theory (resolution of unconscious conflicts between impulse and defence) has changed, in the sense that all unconscious conflicts are considered to be imbedded in unconscious internalized object relations. Such internalized object relations determine both the nature of the defensive operations and of the impulses against which they are directed. These internalized object relations constitute, at the same time, the ‘building blocks’ of the tripartite structure of id, ego, and superego. Object-relations theory proposes that the gradual analysis of intersystemic conflicts between impulse and defence (structured into conflicts between ego, superego, and id) decomposes the tripartite structure into the constituent conflicting internalized object relations. These object relations are reactivated in the treatment situation in the form of an unconscious relation between self and significant others replicated in the relation between patient and analyst, i.e. the ‘transference’.

The transference is the unconscious repetition in the ‘here and now’ of unconscious, conflicting pathogenic relationships from the past. The transference reflects the reactivation of the past conflict not in the form of a memory, but in the form of a repetition. This repetition provides essential information about the past, but constitutes, at the same time, a defence in the sense that the patient repeats instead of remembering. Therefore, transference has important informative features that need to be facilitated in their development, and defensive features that need to be therapeutically resolved once their nature has been clarified. Transference analysis is the fundamental ingredient of the psychoanalytic treatment.

The psychoanalytic treatment consists of the creation of an atmosphere of safety in which a patient is willing to try to express whatever comes to mind. In 45 to 50 min sessions, three to five times per week, the patient usually reclines on a couch while the analyst, generally sitting behind the patient, helps the patient become aware of his or her defensive operations (‘resistances’) by means of interpretations. The systematic interpretation of resistances gradually permits an ever-growing freedom of free association, and helps the patient to become aware of his or her unconscious desires and fears, phantasies and terrors, traumatic situations, and unresolved mourning. Defensive operations are usually classified as ego defences (in the form of the mechanisms listed earlier), superego defences in the form of excessive guilt feelings activated during the treatment, id resistances in the form of repetition compulsion, the development of secondary gain from symptoms as a powerful resistance, and, last and most importantly, the transference as the dominant resistance and source of information.