The drive model posits the existence of libidinal and aggressive drives that fuel all mental activity. Mental content may be unconscious, preconscious, or fully conscious, and the execution of drive activity is mediated by the three structures. Id is the most primitive structure, seeking immediate and unqualified gratification of drive hungers. Superego is the societally driven structure that establishes ideals of behavior and punishes transgressions. Ego is the navigating and executive structure, mobilizing motor and cognitive powers to fulfill id desires by manipulating the environment or by performing internal mental operations to attenuate the drives. Foremost among these latter measures is the array of defense mechanisms that allow ego to keep id, superego, and reality in some dynamic balance. Psychopathology results when drive urges overwhelm the ability of the various structures to gratify or contain them. The same defenses that serve the ends of id and ego can also cause emotional distress and behavioral dysfunction.

In giving birth to psychoanalysis, Sigmund Freud, flush with his early successes in treating hysteria, assumed that alleviation from symptoms would come directly and simply from awareness of their unconscious origins. From the narrow range of his early exposures, he concluded that all hysteria was the outcome of prior trauma. Every life experience, he reasoned, is accompanied by a quota of emotion, which is normally released in a nonsymptomatic way. Traumatic experiences are accompanied by excess emotion, which cannot be discharged through normal means. Therapy required “abreaction,” the reawakening and release of memories and emotions in the present. When met with the verbal responses of the analyst, such abreaction would not only release the “strangulated” affect but would also give a conscious, rational framework for the pathogenic memories and permit correction by association with more adaptive thoughts. Working purely within the topographic model, his goal was “to make the unconscious
conscious.” By recovering memories under hypnosis, then later by encouraging patients to delve into their memories without censorship (“free association”), he relied on the recovery of repressed memories and ideas to cure neurotic symptoms.

Before long, it became apparent that pure awareness was insufficient for most patients. They would distort memories and perceptions; they would substitute new symptoms for old ones; and they would repeat pathological patterns of behavior. He saw that the symptoms were not merely the result of constitutional weakness, but comprised a particular effort of the mind to deal with intolerable clusters of memory, thought, and emotion by revising or expelling them. As the subtleties of repression and distortion revealed themselves in analysis, Freud found that he needed further to interpret the meanings of symptoms. As the structural model evolved and analysts became aware of the multiplicity of maneuvers and tools available to the ego, the aim of therapy shifted. The analyst now sought to understand the meanings of symptoms and to determine motivations. The key element of therapy was not just awareness but interpretation. Said Freud, “Where id was, there ego shall be.” (See Table 8-1.)

Change in symptoms, behavior, emotion, and even personality could result from this self-awareness when the patient became:

The achievement of these simple ends was confounded by several factors. Simple encouragement did not always bring unconscious memories to the fore. Repression was a powerful force,
and the defenses obscured the analyst’s vision of the unconscious mind. Furthermore, the patient’s distortions were not limited to alterations of memory, but affected how he or she perceived others in his or her life, including the analyst. Freud and his early colleagues noted that patients recognized their analysts as characters from their pasts, playing out on them the manifestations of drive-based wishes and fears. Because old patterns were transferred into the present, this pattern became known as “transference.”

Sigmund Freud had the creativity to perceive resistance and transference as more than just impediments to therapy but also as a field of investigation on the path to cure. Since brute force of persuasion could rarely penetrate the resistances, the best alternative was to analyze the resistances themselves. In doing so, the analyst obtained a richly textured picture of the workings of the ego by observing its defenses in operation. Even more so, the analysis of transference yielded tremendous insights. As drive urges, ego defenses, and superego fright were manifested in vivo, the analyst could deal with otherwise unconscious material directly in the consulting room. By observing the patient’s responses to environmental stimuli, the analyst could determine the motivation and meaning in the pattern of defense, resistance, and transference. When the analyst does not behave like the original object, the analytic patient becomes aware of the discrepancy, disrupting the automatic patterns to which the patient has become accustomed, and change becomes possible.

In the formal process of psychoanalysis, the patient does more than play out symptoms in the transference. He or she recreates the totality of the pathogenic neurotic conflict within the analytic setting, including the analyst as a figure in that constellation. This configuration is termed the transference neurosis and is critical to the success of a classical psychoanalysis. The analysand’s attention shifts away from exclusive focus on events and personalities outside the analysis and directs itself toward the person of the analyst and the environment of the consulting room. The analyst allows these perceptions, complaints, and demands to unfold—an often uncomfortable passage for both parties—offering interpretations of parallels to the pathogenic situation. Since these interpretations now strike “closer to home” than those about external circumstances (after all, the party offering the interpretations is in fact the primary object of the patient’s distortions), the resistances are denser and more complex. By the same token, when they have
been absorbed and implemented (see below), their power is profound, since the interpretations have been offered and the changes made in vivo, and the patient has come through the experience of understanding his or her neurosis from the inside out, solving its riddles with the aid of an active party to the conflicts.

When an interpretation is offered, a repressed conflict is mobilized and enters consciousness, if only partially. This revelation induces anxiety, which both mobilizes further defenses and also drives the pursuit of change through the analytic process. As the patient comes to perceive the differences between the transference object and the original object, cognitive mastery makes the energy available to the ego. True structural change occurs as ego is strengthened by the energy that was formerly connected to repressed drives and conflicts.