Topic Adlerian and Psychoanalytic Therapy

Chapters for the Discussion Assignment

Chapters 4

Psychoanalytic Therapy

Sigmund Freud (1856–1939), the founder of psychoanalysis, is still a towering figure in the field of counseling and psychotherapy. Some authors and textbooks have erroneously credited him for being the founder of psychotherapy, but other important figures, such as Paul Dubois (1848–1918) and Pierre Janet (1859–1947), were also influential in the history of modern psychotherapy (see Corsini & Wedding 2008, 11–12). In fact, therapeutic work in the care of souls preceded Freud by many centuries. However, the theories and therapeutic techniques developed by Freud in psychoanalysis are still unique and substantial. Although the Freudian psychoanalytic approach is no longer as popular or widespread today, it is still influential in the development of more recent psychoanalytic or more broadly psychodynamic approaches to therapy that have gone beyond some of Freud’s original ideas. Examples of such contemporary psychoanalytic therapies include ego psychology, object relations psychology, self psychology, and relational psychoanalysis, which will be briefly described later in this chapter. Of course, other schools of therapy have been developed in reaction to Freud’s psychoanalytic views and even in outright rejection of many of his ideas and techniques.

Biographical Sketch of Sigmund Freud

Sigmund Freud was born to Jewish parents in Freiburg, Moravia (formerly in Austria, now in the Czech Republic), on May 6, 1856, the eldest of eight children (five daughters and three sons). The Freud family moved to Vienna when Sigmund was four years old so that his father, who was a wool merchant, would have better business prospects. In their crowded apartment, Sigmund had his own study and bedroom. His mother favored him and had high expectations for him to excel academically and professionally. His father was very authoritarian, like many fathers in that era and culture (E. Jones 1953).

Freud excelled in his academic work and graduated summa cum laude from secondary school. He was fluent in several languages, including the classical languages Greek, Latin, and Hebrew, as well as English, Italian, French, and Spanish (Ellenberger 1970). Eventually Freud decided on a career in medicine and obtained his medical degree from the University of Vienna in 1881, when he was twenty-five years old. He married Martha Bernays in 1886, and they had six children. Their youngest child, Anna Freud, eventually became a well-known psychoanalyst herself, focusing on the treatment of children and on the development of the ego, that system of personality in Freudian theory that interacts with the reality-based external world.

Freud had been exposed to the work of Josef Breuer on hysterical illness during the six years he worked with Ernst Brucke, a well-known physiologist, while still in medical school. Due to financial reasons, Freud left Brucke and began a residency in surgery. In 1883 he trained in neurology and psychiatry at the Viennese General Hospital. He also spent four months in 1885 in Paris with Jean Charcot, a renowned neurologist who used hypnosis to treat hysterical symptoms. This experience enabled Freud to recognize the significance of the unconscious mind, although he later questioned the usefulness of hypnosis as a therapeutic technique. He also discussed with Josef Breuer how Breuer helped his patient Anna O., who had exhibited hysterical symptoms, by mentioning emotional material while she was under hypnosis. Freud began using this technique with his own patients, and he and Breuer published Studies on Hysteria in 1895.

Freud’s father died in 1896; around this time his collaboration with Breuer also began to deteriorate. Freud’s radical views on how traumatic sexual experiences in childhood can cause hysteria did not sit well with others, including Breuer. In 1897, in his early forties, Freud began a painful three-year process of psychoanalysis on himself, including analyzing his dreams and exploring his own childhood memories. He suffered from significant emotional problems at this time, such as serious worries about his finances and phobias of death and heart disease. Through his self-analysis, Freud came to realize that he had strong feelings of hostility toward his father and sexual feelings as a child toward his mother. From his own self-observations and reflections, as well as his treatment of patients, Freud continued to develop his unique psychoanalytic theory and psychoanalysis as a major therapeutic approach. After this intensive three-year period of self-analysis, he published his best-known work, The Interpretation of Dreams, in 1900.

In 1902 Freud formed the Wednesday Psychological Society, which met initially at his home to discuss his psychoanalytic ideas. In 1908 this group became the Vienna Psychoanalytic Society, numbering among its members prominent and brilliant colleagues of Freud, such as Alfred Adler, Carl Jung, and Otto Rank. However, many of Freud’s colleagues were alienated by his inability to tolerate dissenting views and his insistence on having absolute control of what constituted psychoanalysis, as its founder. As a result, key figures such as Adler and Jung eventually left the Vienna Psychoanalytic Society. Adler went on to establish his own school of psychotherapy, called individual psychology; Jung likewise founded another school of psychotherapy, called analytical psychology.

Freud thus spent the later part of his professional life in relative isolation, working more on his own while, ironically, becoming more renowned and successful. He continued to keep a grueling schedule, working eighteen-hour days, seeing patients and writing. Freud habitually smoked twenty cigars almost daily, and in 1923 he was diagnosed with bone cancer of his jaw and mouth. He eventually underwent thirty-three operations, but despite his painful struggle with bone cancer for most of the final two decades of his life, he continued to work long hours and produced many significant writings. Freud reluctantly left Vienna for London in 1938, just before World War II. A year later, in September 1939, he died, probably from physician-assisted suicide, using a lethal dose of morphine (Gay 1988). Freud left behind what many still consider to be the most comprehensive and substantial theory of personality, psychopathology, and psychotherapy in his unique approach of psychoanalysis. His published collected works ultimately included twenty-four volumes (see Standard Edition of the Complete Works of Sigmund Freud, published by Hogarth Press, London, 1953–1974).

Freud’s life and work have been described in more detail by several authors. For further information and details of Freud’s life and professional career, see Ernest Jones (1953, 1955, 1957, also 1961), who gives the most complete account, as well as Henri Ellenberger (1970), Peter Gay (1988), Paul Roazen (2001), and Amy Demorest (2005), as recommended by Richard Sharf (2016, 33).

Major Theoretical Ideas of Freudian Psychoanalysis

Perspective on Human Nature

Freud’s view of human nature was mainly pessimistic and at best somewhat neutral. It was also a deterministic view, in which human actions or behaviors are understood as caused by irrational forces, mainly unconscious, called drives or instincts. These innate instincts evolve through several stages of psychosexual development in a person’s childhood so that their personality is essentially formed by the age of six.

Freud divided such human drives or instincts into two major types: the life instincts (Eros) and libido, originally referring to sexual energy but eventually broadened to include all life energy that seeks to experience pleasure and avoid pain; and the death instincts (Thanatos), which are associated with death and aggression. Both of these sexual and aggressive drives, life-and-death instincts, are crucial motivators of human action according to Freud.

The Unconscious and Levels of Consciousness

Freud’s concepts of the unconscious and of the different levels of consciousness that exist in a person are often viewed as his most significant contributions to the mental health field. He described three levels of consciousness: the conscious, the preconscious, and the unconscious. The conscious, what one is aware of experiencing at a particular moment—such as holding a pen in one’s hand or feeling painful sensations—is actually only a small part of a person’s mental life. The preconscious includes memories that can be easily recalled, such as remembering what one ate for lunch yesterday or details from a movie seen last weekend. The largest level of consciousness, however, is the unconscious, which contains memories and experiences that have been repressed or pushed out of consciousness because they are too threatening, such as feelings of hostility toward a parent or painful childhood memories of sexual abuse. The unconscious also refers to everything that one is unaware of, including hidden needs and motivations. Freud viewed the conscious level as only a small part of the mind, like the proverbial tip of the iceberg. The unconscious, which exists below the level of awareness, is the largest part of the mind and influences or controls most psychological functioning. It cannot be directly observed but can be inferred from phenomena such as dreams, forgetting a well-known fact or name, and slips of the tongue (e.g., saying “nipple” instead of “ripple”). The major goal of psychoanalysis is therefore to make the unconscious conscious so that a person can have more freedom to choose.

Personality Structure

Freud’s psychoanalytic theory postulates three major systems in the personality structure of each person: the id, the ego, and the superego. These psychological systems should not be understood literally as referring to three physically separate parts of a person. However, the three systems are seen as consisting of psychic energy that is limited in its availability. The id can be conceptualized as the biological system, the ego as the psychological system, and the superego as the social system of personality, broadly speaking (Corey 2021), but all three systems function together as a whole. In a nutshell, the id refers to powerful biological forces, the superego to the conscience, and the ego to the rational system of one’s personality that interacts with external reality and mediates between the id and the superego.

The Id. The id (or “it”) is the original, unconscious system of personality. A person is born with an id, and one might say that an infant is all id. The id is full of psychic or instinctual energy waiting to be discharged so that homeostasis can be maintained. It is driven by the pleasure principle, seeking always to avoid pain and to experience pleasure and satisfaction of its intrinsic needs. The id remains so throughout a person’s life, wishing and acting to fulfill desires without rational thinking. The id therefore is characterized by primary process thinking that is irrational and primitive, that seeks self-gratification, with no concern for others. The two basic instincts operating in the id are the life (or sexual) and death (or aggressive) instincts or drives. The newborn infant therefore invests emotional energy, or cathects, in objects that will immediately meet or fulfill its demanding needs. The object may be a nipple or a blanket that serves to reduce the infant’s needs.

The Ego. The ego (the “I”) is the system of personality that interacts with the real world “out there.” It can be likened to an executive who provides control and regulation of one’s personality. It begins functioning around age six to eight months to help the id fulfill its demanding needs and impulses in a more appropriate and acceptable way in the real world. The ego therefore acts to control consciousness and regulate the primitive drives or instincts of the id. The ego follows the reality principle, using rational and realistic thinking, or secondary process thinking, which results in action plans for meeting needs that do not impulsively follow the pleasure principle but instead suspend or control it. It therefore censors and restrains the id, a function described as anticathexis. The ego, in this context, helps an infant or young child not to act out angrily or cry when personal wishes are not fulfilled.

The Superego. The superego is the social or judicial system of personality that contains the social and parental values and standards to which a person has been exposed. It follows the morality principle and guides a person in deciding whether a specific behavior is right or wrong, good or bad. The superego therefore provides a moral code by introjection (the process of incorporating into oneself the values and standards of parents and society). The id impulses are controlled or restrained by the superego, but the ego is also influenced by the superego to aim for perfection and moralistic ideals rather than more realistic and reasonable goals. The superego therefore strives for perfection, not pleasure, and can push a person into an extreme or legalistic submission to perfectionistic and pathological standards that cannot be attained. When this happens, when the superego is functioning against both the id and the ego, neuroses or psychological disorders can develop. Anxiety is often experienced by a person when the id, the ego, and the superego are in such conflict.

Anxiety

Anxiety is a central concept in psychoanalytic therapy. It refers to a feeling of dread and tension resulting from previously repressed factors coming to awareness, such as feelings, experiences, and memories. Anxiety functions as a warning of potential danger and also motivates people to act in certain ways (see Corey 2021, 61).

Freud conceptualized anxiety as consisting of three major types: reality, neurotic, and moral. Reality anxiety is the fear of an external situation that is appropriate to the degree of real danger present, such as fear of a nearby poisonous snake about to strike. Neurotic anxiety is the fear of being overwhelmed by one’s instincts or drives (id) so that one ends up doing something that will be punished. Moral anxiety is the fear of violating one’s own conscience or internalized parental and societal standards (superego). Neurotic and moral anxieties are therefore related to conflicts or threats within the person. When an individual experiences anxiety, the ego copes or responds by using defense mechanisms.

Defense Mechanisms

The ego employs defense mechanisms or ego-defense mechanisms (Corey 2021, 61) to deal with the pain of anxiety by distorting or even denying reality. Defense mechanisms operate at the level of the unconscious. When the ego uses them infrequently and appropriately, they can serve a constructive purpose by reducing stress or anxiety and enabling the person to cope more effectively. However, if they are used too often to avoid the pain of anxiety by denying or blocking out reality, they can become destructive and pathological, resulting in more severe psychological disorders. Common defense mechanisms include repression, denial, displacement, sublimation, reaction formation, projection, rationalization, regression, intellectualization, and identification.

Repression. Freud considered repression the most fundamental or important defense mechanism, one on which his psychoanalytic theory was founded. Repression is the unconscious attempt of the ego to block out of consciousness (i.e., repress) negative experiences that are too painful or threatening for a person to acknowledge. Especially painful experiences or memories of the first five to six years of a person’s childhood are repressed, so that they are stored in the unconscious. However, they still affect and motivate the thoughts, feelings, and behaviors of the person later in life. An example of repression would be a man who has feelings of hostility and hatred toward his father, but these feelings are entirely repressed or blocked from conscious awareness because they are too overwhelming for the person to acknowledge. Such repressed feelings are not under the voluntary control of an individual because repression operates at the unconscious level.

Denial. Denial is a defense mechanism that usually functions at more preconscious and even conscious levels, whereby an individual refuses to accept the reality of a given situation or event that is negative, painful, or anxiety provoking. This mechanism therefore denies reality. For example, an individual refuses to accept the news of having cancer and continues to live as if not having cancer, without getting much-needed medical treatment. In another example, some fanatical fans of Elvis Presley still deny that he is dead!

Displacement. Displacement is a defense mechanism whereby an individual copes with anxiety by shifting the discharge of their impulses from a threatening object or person to a much safer substitute. For example, a very mild-mannered man who has received a strong reprimand from his supervisor at work comes home and kicks his dog (out of frustration and anger toward his supervisor but now redirected to his dog).

Rationalization. Rationalization is an individual’s attempt to explain away painful experiences with reasons or excuses that are not accurate or true. For example, a man who does not get a much anticipated and desired job promotion believes that he really did not want the promotion because of all the extra stresses and responsibilities that come with it, including much international travel.

Regression. When the ego is threatened, an individual may use the defense mechanism of regression, thereby returning to an earlier stage of development that was less stressful but also uses less mature or less appropriate behaviors to cope with the current anxiety. An example can be found in a first grader who is failing academically and then resorts to infantile behaviors such as crying for mother and thumb-sucking.

Intellectualization. Intellectualization is a defense mechanism whereby a person detaches from a painful emotional experience by focusing only on their own thoughts and the minute details involved in trying to analyze and explain the negative emotional experience. For example, a mother who just received news that her two-year-old son was killed by a drunk driver might begin a long discussion of the meaning of life and death and how it is all fated and beyond anyone’s control instead of dealing with her feelings of shock, grief, loss, and anger at the drunk driver.

Identification. Identification is a defense mechanism whereby an individual who is threatened by anxiety or other negative feelings assumes the characteristics of others who may be more successful, thereby associating or identifying with them. An example would be an adolescent who struggles with deep feelings of failure and inferiority who identifies with a famous rock band by dressing like the band members and mimicking their speech.

Personality Development: Freud’s Psychosexual Stages of Development

Freud was radical in his time when he described the psychoanalytic theory of psychosexual stages of development that every person goes through. He believed that the personality development of an individual is basically completed by around age five or six. His theory is biologically based, focusing on the flow of sexual energy through the following psychosexual stages of normal human development: oral, anal, phallic, latency, and genital. The oral, anal, and phallic stages of psychosexual development occur by age five or six, after which comes the relatively calm latency stage, which lasts for about six years. Then the genital stage in adolescence occurs around the onset of puberty. Gratification of the sexual drive is central to Freud’s theory, but this is experienced in various parts of the body as a person matures, eventually culminating in the genital area. If a person experiences certain traumatic events in early childhood in any of these psychosexual stages of development, fixation may then occur at a specific stage, with such abnormal development resulting in an individual being more vulnerable to stress and crisis later in life.

Oral Stage. The oral stage takes place in the first eighteen months of life. It focuses mainly on the mouth for experiencing gratification of the infant’s needs and drives, which are virtually all id-driven at this first and earliest stage. The infant initially is unable to differentiate between self and others or the environment. Dependence on the mother for gratification of the infant’s needs through sucking and eating is crucial; therefore, the mother-infant relationship is central in the oral stage. The mouth is also involved in other activities such as biting, spitting, holding on to, and closing, plus eating and sucking. The specific experiences of the infant or child in the oral stage will affect the person’s adulthood. For example, if the child depends too much on the mother and she overindulges the child, the child may experience fixation at this oral stage and later become an overdependent adult. However, if the mother underindulges the child and provides irregular or inattentive feeding, the child may become insecure and have trouble trusting others or forming intimate relationships with others as an adult.

Anal Stage. The anal stage occurs between the ages of eighteen months and three years, when the focus of gratification and pleasure is the anal area, involving the holding or releasing of feces or the defecation processes, as well as urination. During this anal stage, the ego begins to differentiate from the id. Children are also learning to have more control over their own bodily processes as well as control over others (e.g., by often saying, “No”). Toilet training is a central developmental task in the anal stage. Depending on how strict parents are in toilet training their children, the child may later develop an obsession with cleanliness and orderliness, with a fixation on this stage described as being anal-retentive; or the child may become disorderly and even destructive, that is, anal-expulsive.

Phallic Stage. The phallic stage occurs around the age of three to five or six years, when the gratification of sexual needs moves from the anal area to the genital area. Self-stimulation of the penis for boys and the clitoris for girls (masturbation) leads to pleasurable experiences. The realization that boys have penises but girls do not is a crucial part of the phallic stage, leading to what Freud called penis envy (or wishing to have a penis of one’s own) in girls and castration anxiety (or the fear of losing one’s own penis) in boys.

Boys also have an unconscious sexual desire for their mothers and wish to get rid of the father as a rival. They resolve this Oedipus complex by identifying with the father and channeling their sexual wishes into more acceptable outlets. Girls, in a somewhat different way, have an unconscious desire for their fathers (who have their desired object, a penis) and a hatred for their mothers; Carl Jung and others have labeled this the Electra complex, a term that Freud himself was reluctant to use. Girls also need to resolve this complex by identifying with their mothers so that they can vicariously have the desired object. This aspect of Freudian psychoanalytic theory has received strong criticism from other theorists and feminists. Problems leading to fixation at this phallic stage may result in sexual identity difficulties in adulthood and possible difficulties in relationships with the opposite sex or with the same sex.

Latency Stage. The latency stage occurs from around the age of six to twelve years or puberty. It is a period of relative calm, with sexual drives being more repressed. Children at this latency stage spend more of their energy focusing on school and friends and developing important social and technical skills to prepare them to function well as adults in society. Their personalities have already been formed in the previous stages of psychosexual development, by age five or six, after which Freud believed that significant personality change is almost impossible.

Genital Stage. At puberty, around age twelve, an individual enters the genital stage, when pleasure is experienced more directly through genital stimulation in the context of heterosexual relationships. The focus now is on others rather than on the self, in the experience of genital sexual satisfaction. If a person has gone through the other earlier stages of psychosexual development without significant fixations or traumas, then there is sufficient libidinal energy available for the youth to live a relatively normal life. Such a life means having the ability to love and to work, the ideals of personal maturity that psychoanalysts try to help their patients achieve in successful psychoanalysis.

Freud’s theory of psychosexual stages of development has been strongly challenged and criticized by other psychoanalytic theorists. Erik Erikson (1902–1994), for example, emphasized much more the psychosocial stages of development, focusing not only on child development but also on the entire adult span of human development until death. Briefly, Erikson (1950) delineated and described the following stages of psychosocial development:

infancy (first year of life), focusing on developing trust versus mistrust

early childhood (ages one to three), focusing on developing autonomy versus shame and doubt

preschool age (three to six), focusing on developing initiative versus guilt

school age (ages six to twelve), focusing on developing industry versus inferiority

adolescence (ages twelve to eighteen), focusing on developing identity versus role confusion

young adulthood (ages eighteen to thirty-five), focusing on intimacy versus isolation

middle age (ages thirty-five to sixty), focusing on developing generativity versus stagnation

later life (ages sixty plus), focusing on developing integrity versus despair

Joan Erikson, Erikson’s wife for sixty-four years, more recently included another stage that she termed “disgust versus wisdom” (ages in the eighties and nineties), focusing on developing gerotranscendence (Sharf 2016). This ninth stage of psychosocial development involves moving from a rational and materialistic perspective to a deeper focus on spirituality and experiencing peace of mind (Erikson 1997).

Other challenges and modifications to traditional psychoanalytic theory as originally described by Freud have come from more contemporary approaches to psychoanalytic therapy and, in particular, the four major schools: ego psychology, object relations psychology, self psychology, and relational psychoanalysis.

Ego Psychology

Ego psychology focuses more on the ego and its conscious and adaptive functions rather than on the id and unconscious drives, which seemed to preoccupy Freud. Anna Freud (1895–1982), Sigmund Freud’s daughter, made significant contributions to ego psychology by emphasizing the ego in child development in her description of developmental lines, an example of which is the gradual evolving of more other-centered behaviors rather than self-centered behaviors as a child matures (A. Freud 1965). She also expanded the notion of defense mechanisms to include normal and constructive ones that enable an individual to deal more effectively with the world (A. Freud 1936). As already mentioned, Erik Erikson is another major theorist in ego psychology, noted especially for his description of the psychosocial stages of human development over the entire life span of an individual. Other well-known figures in ego psychology, sometimes labeled as “the American school,” include Heinz Hartmann (1958) and David Rapaport (1951).

Object Relations Psychology

The object relations perspective focuses more specifically on how past childhood relationships between a child and the child’s significant others, especially the mother or other love objects in the child’s life, affect personality development and later adult life. It also emphasizes past internalized relationships or object relations rather than internal sexual or aggressive drives in the determination of one’s present and future behavioral patterns. A specific process described by object relations theorists as individuation refers to how an individual can separate from their mother and develop into an independent person. Well-known theorists in object relations psychology, sometimes described as “the British school,” include Donald Winnicott (1966), W. R. D. Fairbairn (1954), Melanie Klein (1957, 1975), Margaret Mahler (1968, 1979a, 1979b), and Otto Kernberg (1975, 1976). More detailed descriptions of object relations approaches can be found in St. Clair and Wigren (2004).

Self Psychology

The self psychology school is based on the major contributions of Heinz Kohut (1913–1981), who wrote several significant books (1971, 1977, 1984) that define and describe his theoretical concept of the self (see also St. Clair & Wigren 2004). He emphasized how relationships with other people, especially parental figures in childhood experiences, have a profound influence on the development of the sense of self in an individual. If such childhood experiences have been nurturing and healthy, a stable sense of self will result so that one is able to develop mature relationships with others as an adult. However, if early childhood experiences have been more negative and emotionally depriving, then a less healthy sense of self will result, and the person’s ability to relate to others well will be significantly limited. Kohut especially focused on the treatment of narcissistic and borderline disorders that involve a person’s sense of a damaged or inadequate self.

Relational Psychoanalysis

A more recent development in psychoanalytic theory and therapy has been the significant work of Stephen A. Mitchell (1988, 2000) and his colleagues (see J. R. Greenberg 2001; J. R. Greenberg & Mitchell 1983) on relational psychoanalysis. This approach emphasizes the mutuality of the therapeutic relationship between the analyst and the client. In other words, both the analyst and the client influence each other on the conscious and unconscious levels such that the analytic or therapeutic relationship cannot be viewed as neutral, with the analyst objectively observing and analyzing the client in a unilateral way. This relational perspective has been described as intersubjective (see Orange, Atwood, & Stolorow 1997; Stolorow, Atwood, & Brandchaft 1994; Stolorow, Brandchaft, & Atwood 1987), interpersonal, or relational (see Wachtel 2008; also Bland & Strawn 2014a; M. T. Hoffman, 2011). Mitchell alsoalso focused on how culture affects both the analyst and the client, thus critiquing and moving beyond Freud’s original idea of unconscious biological drives that affect every individual because they are supposed to be universal in nature.

These four major schools of contemporary psychoanalytic approaches have critiqued and modified traditional Freudian psychoanalysis. Psychoanalytic therapy today is more diverse and less authoritarian, especially regarding how the analytic relationship is viewed and experienced. Examples of the newer approaches to psychoanalytic theory and practice are a greater emphasis on the conscious and adaptive functions of the ego (and less on the unconscious drive of the id), on object relations or internalized relationships with significant others or love objects, on the development of the self, and on a more mutual and reciprocal analytic relationship between the analyst and the client.

Another significant development in recent years has been the ascendency of attachment theory, based on the pioneering work of John Bowlby (1969, 1977, 1988) and Mary Ainsworth (Ainsworth et al. 1978), not only in developmental psychology (Dixon 2003) but also in psychotherapy and, more specifically, psychoanalytic therapy and psychodynamic therapy. This has resulted in several attachment-theory-based, or attachment-based, child and family interventions, as well as several attachment-based adult therapies (see K. N. Levy & Johnson 2019; see also Cassidy & Shaver 2016; Mikulincer & Shaver 2016).

Attachment Theory and Attachment-Based Therapies

Bowlby (1969, 1977) was the originator of attachment theory, which emphasizes that the affectional bond between an infant and the caregiver, developed from their early interactions, leads to one’s “internal working models” of self and the other (Bowlby 1977). Secure attachment between an infant and the caregiver results from a caregiver who sensitively and consistently gives love, comfort, food, and warmth to the infant. The infant experiences such a caregiver as a safe haven to turn to when facing distress or other needs, and also as a secure base who will watch over the infant venturing out to explore the environment. However, if the infant’s needs are not reliably and lovingly met by the caretaker (usually the mother), insecure attachment occurs, which can lead to vulnerability and psychopathology and even specific problems or disorders (see K. N. Levy & Johnson 2019, 179). Ainsworth further developed attachment theory with more empirical work (Ainsworth et al. 1978). Based on observational studies of mother-infant interactions in the “strange situation” involving experiences of separation and reunification, three major classifications of attachment were identified: secure attachment, anxious-avoidant attachment, and anxious-ambivalent (or anxious-resistant) attachment. Disorganized attachment was a later fourth classification that was added. Bowlby’s attachment theory was initially rejected by mainstream psychoanalysis but more recently has become a major theoretical framework for clinical work (e.g., see Obegi & Berant 2009) with emerging attachment-based psychoanalytic therapies (see T. W. Hall & Maltby 2014; see also Eagle 2013; Fonagy 2001; K. N. Levy & Johnson 2019; Wallin 2007).

Mary Main, who studied with Ainsworth, developed the semi-structured adult attachment interview with her students Nancy Kaplan and Carol George (Main, Kaplan, & Cassidy 1985; George, Kaplan, & Main 1985), which led to further significant developments in attachment theory. They identified three major adult attachment patterns: secure, dismissing, and enmeshed/preoccupied, with two later additional categories of unresolved and “cannot classify” (see K. N. Levy & Johnson 2019, 179). A self-report measure of adult attachment style has also been developed by Cindy Hazan and Phillip Shaver (1987), with three major scales: secure, anxious, or avoidant, following the earlier infant-strange-situation classifications. A fourth category of fearful attachment was added by other researchers (Bartholomew & Horowitz 1991).

Kenneth Levy and Benjamin Johnson (2019), in their comprehensive and empirically based review of attachment and psychotherapy, noted that several attachment-based parent-child interventions and psychotherapies were developed in the 1980s and 1990s; since then, even more have emerged. They briefly list and describe twenty-one of these child and family interventions, some of which have received empirical support for their effectiveness (180–183). They also list seven attachment-based adult interventions, focusing on three major therapies that are explicitly based on attachment theory and have received some empirical support for their effectiveness in treating several psychological disorders (183–186).

The first major attachment-based adult therapy is interpersonal psychotherapy or IPT (Klerman et al. 1984; see also E. Frank & Levenson 2010; Verdeli & Weissman 2019; Weissman, Markowitz, & Klerman 2017). It is based on psychodynamic neo-Freudian theory that is more interpersonally oriented (e.g., the work of Karen Horney, Harry Stack Sullivan, Erich Fromm, Clara Thompson and Frieda Fromm-Reichman, as well as Franz Alexander and Thomas French, who emphasized the corrective emotional experience between the therapist and client, and especially the work of Sullivan and Bowlby). It is a structured and time-limited therapy that focuses on the therapist interpersonally providing a secure base and safe haven in therapy for the client to experience attachment security with a warm, empathic, collaborative, and active therapist who is not too directive. It also uses psycho-education and homework assignments. IPT has been found to be as effective as cognitive-behavioral therapy (CBT) for major depressive disorder but has also been further developed to treat other problems such as eating disorders and addictions (see Carroll, Rounsaville, & Gawin 1991). A quite similar therapy to IPT, attachment-based family therapy (ABFT), has shown effective results for adolescents suffering from family conflict, internalizing and externalizing behaviors, anxiety, depression, suicidality, and hopelessness (G. S. Diamond, Wintersteen, et al. 2010). In fact, numerous randomized clinical or controlled trials have been conducted, and the results from the meta-analyses (Cuijpers et al. 2011, Cuijpers, Donker, et al. 2016) support the efficacy of IPT for mood disorders, some anxiety disorders, and bulimia nervosa, but not for anorexia nervosa or substance abuse (see Prochaska & Norcross 2018, 169–171; see also Verdeli & Weissman 2019).

The second major attachment-based adult therapy is emotion focused or emotionally focused therapy (EFT) for couples, but more recently it has been used also for individuals and families. Susan Johnson (2019), the primary developer of EFT, recently provided an update of EFT and the empirical evidence that has accumulated for its efficacy as an attachment-based therapy and now as an empirically supported treatment. She also summarized ten core principles of attachment theory and science that are foundational to EFT (2019, 6–9). While EFT is attachment based, emotion centered, and relational, with some connection to relational psychodynamic therapies, it is not strongly psychoanalytic in orientation.

Levy and Johnson (2019) mentioned three steps that EFT implements to help couples, using an attachment injury resolution model (see Makinen & Johnson 2006): First the therapist guides the couple to view their troubling emotions from an attachment perspective (e.g., in discussions of fears related to closeness or loss). Second, the therapist encourages the couple to communicate more openly about their needs and interpersonal risk-taking in order to deepen an attachment bond between the couple. Third, as the couple develops more attachment security, other secondary issues (such as drinking problems) can be better dealt with in their relationship, which now has a strong love connection or attachment bond (see K. N. Levy & Johnson 2019, 183, 185). There is some empirical evidence to support the effectiveness of this EFT intervention (Makinen & Johnson 2006) and the stability of the improvements over a three-year period (Halchuk, Makinen, & Johnson 2010).

Susan Johnson (2019) has written about EFT as an attachment-based therapy that focuses on love or developing strong attachment bonds in couples and between people. She has described it as a “hold-me-tight” approach (S. M. Johnson 2008) with love sense, which emphasizes love as key and crucial to human relationships and a civilized society (S. M. Johnson 2013). She has also coauthored a hold-me-tight guide from a spiritual perspective for Christian couples called Created for Connection (S. M. Johnson & Sanderfer 2016). Further descriptions of EFT can also be found in chapter 16 on marital and family therapy (below; see also L. S. Greenberg 2017; L. S. Greenberg & Goldman 2019).

The third major attachment-based adult therapy is mentalization based treatment (MBT), developed by Peter Fonagy and Anthony Bateman, initially in the treatment of borderline personality disorder (Bateman & Fonagy 1999, 2009, 2012, 2016; Fonagy & Bateman 2006). MBT combines philosophy or theory of mind, Kleinian theory, ego psychology, and attachment theory (K. N. Levy & Johnson 2019, 185). Mentalization refers to the social-cognitive-affective capacity to think about mental states (e.g., wishes, desires, and intentions) in oneself and in others. MBT therefore focuses on reflective function as a core aspect of therapy in helping clients develop their mentalizing capacity to be more aware of one’s own thinking and internal states as well as others’ thinking and internal states, including the therapist’s, and be better able to process them. The therapeutic relationship between the therapist and client is crucial in MBT, which is a relational psychoanalytic therapy that is also attachment-based. Growing empirical evidence for the efficacy of MBT, especially for borderline personality disorder and maintenance of treatment gains compared to treatment-as-usual, has been found in two large-scale randomized controlled trials involving eighteen months of MBT in outpatient treatment as well as in a day hospital program (Bateman & Fonagy 1999, 2009). MBT is now also being used in the treatment of mood disorders and somatoform conditions, and of youth and family problems (Bateman & Fonagy 2012).

Levy and Johnson (2019) noted that in addition to these three major explicitly attachment-based therapies, there are two other examples of therapies indirectly or implicitly based on attachment theory in emphasizing the therapeutic alliance between the therapist and client and the exploration of past and present relational experiences so that more adaptive views of self and other may occur. These two therapies are supportive psychodynamic psychotherapy (SDT), which is an object relations and psychoanalytically oriented treatment for borderline personality disorder (Appelbaum 2005), and transference-focused psychotherapy (TFP), which is a psychoanalytically oriented therapy with some integration of attachment theory in its focus on reflective function (Clarkin, Yeomans, & Kernberg 2006), based on the object relations work of Kernberg (1968). SDT has received some empirical support for its effectiveness in treating personality disorders (e.g., Clarkin et al. 2007); TFP has also been found to be effective for the treatment of personality disorders such as borderline personality disorder and narcissistic personality disorder (Clarkin et al. 2007; D. Diamond et al. 2013).

Attachment theory across the life span and in many areas of psychology and other disciplines has exploded in its growth in recent decades, with over thirty thousand entries in a literature search from 1975 to 2016 (Cassidy & Shaver 2016, x). Mikulincer and Shaver (2016) found the huge literature published on attachment theory “daunting” in 2007 but observed that it had become “gargantuan” by 2016 (ix). Attachment theory has also achieved a more significant and central place in psychoanalytic therapy and psychodynamic therapy. Hall and Maltby thus concluded: “An attachment-based psychoanalytic modality believes that the patient’s attachment to the therapist is primary in the change process. The common interventions . . . focus on the patient-therapist relationship and include attunement/empathic interventions, relational interventions, reflective interventions, appropriate use of interpretation and effective self-disclosure” (2014, 214).

In recent years more work has also been done on the integration of psychoanalytic and psychodynamic therapies, especially relationally based and attachment-based approaches with Christianity or spirituality (e.g., see Bland & Strawn 2014a; M. T. Hoffman 2011; Rizzuto & Shafranske 2013; Sorenson 2004).

The therapeutic process and relationship as well as the major therapy techniques and interventions of more traditional psychoanalytic therapy will now be discussed.

Therapeutic Process and Relationship

Traditional Freudian psychoanalysis (with the analyst seeing the client usually four times a week, sitting behind the client, who lies on a couch) and psychoanalytic therapy (with the analyst seeing the client one to three times a week, usually face-to-face) have two main goals of therapy: to help bring the unconscious to conscious awareness and to strengthen the ego so that an individual is less influenced by instinctual drives (sexual and aggressive) of the id or demanding perfectionist standards of the superego, and freer to act in more realistic ways. Psychoanalysis therefore aims at restructuring one’s personality and not simply attenuating symptoms or solving problems. Insight or understanding of childhood experiences is achieved by analyzing them through using several major psychoanalytic methods of therapy. Such insight is seen as a key curative factor in successful psychoanalysis. However, it is not merely intellectual insight or understanding; it is also insight based on working through or experiencing specific memories and feelings, especially from childhood.

The therapist’s role in traditional psychoanalysis is passive, aimed at maintaining neutrality or anonymity, with almost no self-disclosure at all. The analyst therefore behaves like a “blank screen” to facilitate the development of a transference relationship in which the client will project or transfer unconsciously onto the analyst some feelings and experiences that originally were associated with past parental figures, especially in early childhood. The analyst puts forth a best effort to achieve a good working alliance or therapeutic relationship with the client. Most of the time, the analyst is simply listening to the client, occasionally asking key questions, murmuring the proverbial Freudian “Um-hmm,” and judiciously and infrequently interpreting the client’s unconscious material as well as resistances.

Psychoanalysis and psychoanalytic therapy are therefore very intensive forms of psychotherapy, requiring a client to commit to a long-term therapeutic relationship, which can last for several years. The client must be willing to follow the “fundamental rule” of free association—that is, saying whatever comes to mind without any evaluation or censorship—in order to reveal unconscious material for the analyst and the client to explore. This is hard work, and the client’s motivation or readiness to change is crucial for psychoanalysis and psychoanalytic therapy to be successful. Psychoanalytic therapy is usually considered modestly successful if it has effectively helped the client to be able to love and work in life.

Major Therapeutic Techniques and Interventions

Several major therapeutic techniques or interventions in traditional psychoanalytic therapy have been somewhat modified in more contemporary approaches to such therapy (see McWilliams 2004; Summers & Barber 2010). However, the primary methods of traditional psychoanalytic therapy are still foundational. At least six of them are basic to psychoanalytic therapy: “maintaining the analytic framework, free association, interpretation, dream analysis, analysis and interpretation of resistance, and analysis and interpretation of transference” (Corey 2021, 73–76).

Maintaining the Analytic Framework

The analyst listens intently to the client’s free associations, paying special attention to disruptions or blockages in free association, which may indicate the presence of repressed anxiety-provoking material that is beginning to emerge into consciousness. The analyst listens especially for hidden meanings in the client’s free associations and notices slips of the tongue, or Freudian slips, that may be due to unconscious conflicts. Therefore, the analyst does not take whatever the client expresses at face value. In using the technique of free association, the analyst ultimately identifies and interprets unconscious material and conflicts that may emerge, so that the client can gain deeper insight and understanding.

Interpretation

Interpretation is the psychoanalytic technique whereby the analyst clarifies and explains to the client the meaning of certain unconscious material emerging in the client through dreams, free association, experiences in the therapeutic relationship between the analyst and the client, and resistances or blockages. Through interpretation, the analyst enables the client to gain insight into unconscious material that is surfacing and to help the client’s ego deal with such material more effectively and realistically.

Interpretation must be well timed and based on sufficient unconscious material to substantiate the accuracy of that interpretation. Otherwise, “wild analysis,” wild interpretation that is off target, can occur, to the possible detriment of the therapeutic process and the relationship with the client. The readiness of the client to accept a specific interpretation is also a crucial factor. Interpretations are most helpful if they involve material that is preconscious or beginning to become conscious and if they begin with more surface material and proceed to deeper levels of meaning, yet only as far as the client is ready to go.

Dream Analysis

Freud considered dreams “the royal road to the unconscious.” Dreams are the raw material of the unconscious. Dream analysis is therefore another crucial technique in psychoanalytic therapy. The analyst encourages the client to record and report their dreams and free associate to them, saying whatever comes to mind while describing the dreams. The analyst then discusses and interprets the client’s dreams and free associations to the dreams or parts of them that can be viewed on two levels: the manifest content of a dream, referring to the surface material or details of the dream; and the latent content of a dream, referring to its unconscious or hidden meaning. The analyst is especially involved in pointing out and interpreting the latent content and meaning of a dream.

Freud described several dreamed symbols often reported by clients, figures that seem to have consistent meanings for almost every client. Examples are tree trunks and candles representing the penis, and steps and ladders symbolizing sexual intercourse. However, there is a danger of overgeneralizing such symbolic meanings in dreams, so dreams should still be interpreted in the proper context of a specific client’s life.

Analysis and Interpretation of Resistance

Resistance is a basic psychoanalytic concept that refers to a client’s blocking or defending against bringing unconscious and repressed material into conscious awareness, mainly because it is emotionally painful and provokes anxiety to do so. Resistance therefore is a major barrier to therapeutic progress in psychoanalytic therapy. A client can show resistance in various ways, such as being consistently late for appointments, not producing much by way of free associations, talking incessantly about superficial topics like the traffic or sports, and especially by abruptly terminating psychoanalytic therapy early in the therapeutic process.

The analyst will analyze and interpret the client’s resistances so that the client can overcome them and become more aware of unconscious issues and repressed feelings, memories, or experiences. It is crucial, however, for the analyst to first interpret resistances that are clear or obvious to the client so that the client will be more accepting of the interpretation rather than further resist the analyst’s interpretation. The analysis and interpretation of resistance must be conducted in a deeply empathic and clinically sensitive way so that the client’s defenses are not too quickly or harshly confronted. Otherwise, further resistance may result.

Analysis and Interpretation of Transference

Another important technique of psychoanalytic therapy is the analysis and interpretation of transference. Transference occurs when the client unconsciously relates to the analyst as if the analyst were a parental figure from the client’s earlier life, usually childhood. Both positive (e.g., admiration) and negative (e.g., anger) experiences and feelings can occur in transference to the analyst or therapist. The analyst allows the transference to develop and then interprets its meaning to the client. This analysis of the transference helps the client to achieve deeper insight into their past experiences and how they may still be affecting and influencing present relationships and experiences.

The traditional Freudian view is that the analysis of transference is an essential part of psychoanalytic therapy. The analyst also needs to be careful of their own unconscious responses to the client that reflect unresolved issues with significant figures from the analyst’s own past relationships, especially in childhood, a phenomenon known as countertransference. Analysts are therefore required to have their own personal or training analysis and further consultation or supervision, when this is determined to be necessary, in order to become more aware of and minimize countertransference to their clients. More contemporary approaches to psychoanalytic therapy, however, also focus on how to constructively use countertransference for better understanding the client, rather than always viewing countertransference as an inappropriate or unhealthy phenomenon requiring constant vigilance and control by the analyst.

Critique of Psychoanalytic Therapy: Strengths and Weaknesses

Traditional psychoanalysis and psychoanalytic therapy are based on Freud’s theories, which many still consider to be the most comprehensive view of personality, psychopathology, and psychotherapy. Several psychoanalytic concepts such as the unconscious, defense mechanisms, resistance, and transference and countertransference in the therapeutic relationship are still helpful notions being used not only by psychoanalysts and psychoanalytic therapists but also by other psychotherapists. Some therapists have found the psychoanalytic approach to be the richest and deepest in theory and practice among the many psychotherapies available today.

However, Freudian psychoanalytic therapy has several significant weaknesses and limitations. First, although Freud’s psychoanalytic theory is comprehensive, some of his ideas are not easily translated into testable hypotheses that can be verified by empirical research, for example, the id, the ego, and the superego, or Eros (life instinct) and Thanatos (death instinct).

Second, his theory narrowly focuses on sexual and aggressive drives and emphasizes his conviction that biology is destiny. However, there are other motivational forces or drives not considered by Freud that may be equally or even more important than sexual and aggressive instincts in influencing human behavior. Other theorists and therapeutic approaches have emphasized other drives or motivations (e.g., social or spiritual), which will be discussed in later chapters of this book.

Third, some of Freud’s original ideas have been viewed as sexist, especially by women and feminist therapists. For example, penis envy, the Oedipus complex, and the tendency to blame the mother in poor parent-child relationships that supposedly lead to adult psychological disorders—these have all been criticized for denigrating women and viewing them as inferior to men.

Fourth, traditional psychoanalysis or psychoanalytic therapy is an intensive, long-term, and hence expensive form of psychotherapy, which only the relatively wealthy can afford. It is therefore not as suitable for managed care, which emphasizes and covers shorter-term and brief therapies. It also focuses on intrapsychic or personal conflicts and dynamics, often without paying sufficient attention to other real-life concerns such as employment, poverty, and social issues that may be more important and relevant to people from more diverse socioeconomic and cultural backgrounds. From a multicultural perspective, psychoanalysis and psychoanalytic therapy may therefore not be as meaningful or appropriate for some clients from certain ethnic and cultural groups, who may prefer a more direct, problem-solving approach to therapy.

Fifth, the neutral and anonymous therapeutic stance of the analyst in traditional psychoanalysis may be difficult for some clients to tolerate. It may also be experienced by certain clients in a potentially harmful or anti-therapeutic way. The traditional analytic approach also requires a minimal level of ego strength on the part of the client, enabling participation in and benefit from such an intensive and demanding form of therapy. Some contemporary approaches to psychoanalytic therapy, such as relational psychoanalysis, have therefore modified the analytic relationship into one that is more mutual and reciprocal between analyst and client.

Finally, the empirical or research support for the efficacy of traditional psychoanalysis is limited and based on naturalistic studies, not on randomized controlled trials or controlled outcome studies; therefore, no definitive conclusions can be made at this time (see Safran, Kriss, & Foley 2019). For example, Rolf Sandell and colleagues in Sweden conducted a large naturalistic outcome study of over four hundred patients, but with no control groups, and found that both psychoanalysis and psychoanalytic therapy were effective treatments (Sandell 2001, 2012; Sandell et al. 2000, 2002). However, there is now more empirical evidence supporting the efficacy of both long-term and short-term psychoanalytic therapy or psychodynamic therapy, including several randomized controlled trials for a range of psychological disorders (e.g., see Abbass et al. 2014; Driessen et al. 2015; Eagle 2013; Keefe et al. 2014; Leichsenring & Rabung 2011; Leichsenring, Luyten, et al. 2015; R. A. Levy, Ablon, & Kächele 2012; Shedler 2010; Steinert et al. 2017; Town, Abbass, & Hardy 2011; Town et al. 2012). More details are included in the section on “Research” later in this chapter.

A Biblical Perspective on Psychoanalytic Therapy

Freud’s view of human nature was somewhat negative and pessimistic: a person must struggle with the basic aggressive and sexual instincts of the id as well as the perfectionistic standards and demands of the superego, with the ego mediating these extreme forces into realistic compromises so that the person can learn to love and work satisfactorily in life. The biblical view of human nature as sinful and fallen (Rom. 3:23) is somewhat consistent with Freud’s description of the human psyche. However, this is only half the story. The Bible also teaches that we are created in the image of God (Gen. 1:26–27) and therefore have the potential to be somewhat like God in our character, especially if we are in Christ, who makes us part of the new creation (2 Cor. 5:17; cf. RSV) and capable, by the power of the Holy Spirit, to be transformed into deeper Christlikeness (Rom. 8:29). The potential for change through Christ is therefore greater than a purely Freudian view would allow, especially in its deterministic notion that one’s personality is already formed by age five or six (see S. L. Jones & Butman 2011).

Second, Freud emphasizes the unconscious and the need to gain insight that is not only intellectual but also experiential in making the unconscious conscious and resolving intrapsychic conflict; this emphasis points to the need for wisdom and awareness of the darker side of human nature, a view that can be recognized as consistent with biblical teaching (Jer. 17:9). However, his narrow focus on aggressive and sexual instincts in the motivation of human behavior is unbalanced. There are other human motivations such as spiritual longings for God, including agape love for God and for neighbor or the other (cf. Mark 12:30–31), that are real and not pathological obsessional neurosis as Sigmund Freud (1927) claimed in his antireligious views emphasizing that we created God in our own image in wish fulfillment of a longing for a father, rather than that God created us in his image.

Third, the traditional therapeutic stance of the analyst or therapist in staying as neutral and anonymous as possible, with a clinical aloofness that is assumed to facilitate transference, which can then be interpreted by the analyst—such a stance can be viewed as problematic from a biblical perspective that emphasizes the centrality of agape love in all human relationships (1 Cor. 13), including therapeutic relationships (see Browning & Cooper 2004). Contemporary approaches to psychoanalytic therapy such as relational psychoanalysis, however, have modified this traditional analytic stance so that a more mutual and reciprocal relationship between the analyst and the client can be achieved. A Christian approach to relational psychoanalysis will be based more on agape love (see M. T. Hoffman 2007, 2011; see also Bland & Strawn 2014a; Sorenson 2004). Several Christian approaches to contemporary psychoanalytic therapy were described in a special issue of the Journal of Psychology and Theology (35, no. 1, 2007) devoted to psychoanalytic psychotherapy and religion, using a case-study approach, edited by Brad D. Strawn (2007). It was published in honor of the late Christian psychologist and contemporary psychoanalyst Randall Lehman Sorenson and his major work, Minding Spirituality (2004), which focused on the integration of spirituality or religion and psychoanalysis. Some Christian psychoanalysts maintain that the traditional psychoanalytic stance of the analyst is actually a manifestation of deep agape love and empathy for the client.

Research: Empirical Status of Psychoanalysis and Psychoanalytic Therapy

Over the last several decades or so, most outcome evaluations of the effectiveness of psychoanalysis and psychoanalytic therapy have involved uncontrolled case studies and clinical surveys (see Galatzer-Levy et al. 2000; Sandell 2001, 2012; Sandell et al. 2000, 2002; Wallerstein 1986, 1996, 2001, 2009). The best-known and widely published study reported by Robert S. Wallerstein, the Menninger project, was conducted at the Menninger Clinic in Topeka, Kansas; it extended over thirty years and involved extensive assessment and follow-up of forty-two patients, half of whom were seen in traditional psychoanalysis and the other half in psychoanalytic therapy. Wallerstein (1986, 1996, 2001, 2009) concluded that traditional psychoanalysis was less successful than expected, whereas supportive psychoanalytic therapy was more successful than expected, but both were relatively beneficial. He also noted that therapeutic change is not contingent on inner conflict resolution, and interior structural change cannot be clearly differentiated from external behavior change. A larger and more recent naturalistic outcome study of over four hundred patients, yet also with no control groups, was conducted by Sandell and colleagues in Sweden, called the Stockholm Outcome of Psychoanalysis and Psychotherapy Project. They concluded that both psychoanalysis and psychoanalytic therapy were effective treatments (Sandell 2001, 2012; Sandell et al. 2000, 2002). Empirical support for the efficacy of traditional psychoanalysis is therefore limited to naturalistic studies and not based on randomized controlled trials or controlled outcome studies (with random assignment of patients and appropriate control groups); therefore, no definitive conclusions about the efficacy of traditional psychoanalysis can be made at this present time (Safran, Kriss, & Foley 2019; see also Fisher & Greenberg 1996). However, this can no longer be said of the efficacy of psychoanalytic therapy and more broadly psychodynamic therapy, which have received more substantial empirical support in recent years, including a growing number of randomized controlled trials, for both long-term and short-term psychoanalytic and psychodynamic therapies (e.g., see Abbass et al. 2014; Driessen et al. 2015; Eagle 2013; Keefe et al. 2014; Leichsenring & Rabung 2011; Leichsenring, Luyten, et al. 2015; R. Levy, Ablon, & Kächele 2012; Shedler 2010; Steinert et al. 2017; Town, Abbass, & Hardy 2011; Town et al. 2012).

Jonathan Shedler (2010) reviewed the outcome research on psychodynamic or psychoanalytic therapy, whether short-term or long-term, and concluded that the empirical evidence strongly supported the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those found for other empirically supported, evidence-based, treatments. Psychodynamic therapy was also found to have more robust long-term effects, with increasing therapeutic gains over time in follow-up evaluations (see also Driessen et al. 2015). However, a more recent longitudinal meta-analysis examined the long-term effects of psychodynamic therapies versus non-dynamic therapies and found no significant differences at all after treatment (Kivlighan et al. 2015). Psychodynamic and nondynamic therapies therefore showed equivalent enduring effects, contrary to what Shedler (2010) reported earlier. Shedler’s review and conclusions were also methodologically criticized, with rebuttals (e.g., see Anestis, Anestis, & Lilienfeld 2011; D. McKay 2011), focusing on the weaknesses of the studies and meta-analyses that he reviewed (e.g., pooling the effects of poorly designed studies with small samples, use of inadequate outcome measures). Nevertheless, some of his conclusions have received more empirical support in the last decade or so (see studies and reviews cited earlier).

Falk Leichsenring, Frank Leweke, Susanne Klein, and Christiane Steinert (2015)—in a more recent wide-ranging meta-analysis of thirty-nine randomized controlled trials evaluating the efficacy of psychodynamic therapy, using stricter criteria for empirically supported therapies that are “efficacious” or “possibly efficacious”—found that psychodynamic therapy is efficacious for major depressive disorder, social anxiety disorder, somatoform pain disorder, borderline and heterogeneous personality disorders, and anorexia nervosa; they are also possibly efficacious for dysthymia, complicated grief, panic disorder, generalized anxiety disorder, and substance abuse/dependence. There was insufficient evidence for obsessive-compulsive, posttraumatic stress, bipolar, and schizophrenia spectrum disorders. Psychodynamic therapy was also reported to be as effective as other forms of treatment in most comparisons. They therefore concluded that there is strong empirical evidence for the efficacy of psychodynamic or psychoanalytic therapy for a wide range of disorders (see also Leichsenring, Luyten, et al. 2015 for a review of sixty-four randomized controlled trials supporting the efficacy of psychodynamic therapy).

There is now some emerging empirical evidence for the possible relative greater efficacy of long-term psychodynamic and psychoanalytic therapy over short-term psychodynamic therapy (e.g., Leichsenring, Abbass, et al. 2013; see also Huber et al. 2013, Lindfors et al. 2014), but this is not a definitive finding. Both long-term and short-term psychoanalytic therapy have been found to be effective treatments for a variety of disorders. As mentioned earlier, there is also empirical evidence supporting the efficacy of several attachment-based therapies such as IPT, EFT, MBT, SDT, and TFP (see K. Levy & B. Johnson 2019).

More specifically, psychodynamic or psychoanalytic therapy has been found to be as effective as other active treatments in comparative studies, for depression (Driessen et al. 2015; see also Cuijpers 2017) as well as for anxiety disorders (Keefe et al. 2014). A common previous claim of the superiority of cognitive behavior therapy over psychodynamic therapy in the treatment of depression and anxiety disorders is no longer valid and has been challenged and mainly discredited by these recent findings.

The empirical evidence supporting the efficacy or effectiveness of psychoanalytic therapy or psychodynamic therapy, both short-term and long-term, is therefore now rather substantial, but this is still not the case for traditional psychoanalysis that has not been subjected to randomized controlled trials or better-controlled outcome studies instead of just naturalistic studies and surveys. Psychodynamic therapy or psychoanalytic therapy, however, can be regarded as an empirically supported or evidence-based treatment for a range of psychological disorders.

Future Directions

Future Directions

Many authors and counselors have predicted the demise of psychoanalysis and psychoanalytic therapy in the last few decades, but it has not happened. In fact, interest in psychoanalysis and psychoanalytic therapy continues to be strong, even among Christian therapists (see Strawn 2007; also Bland & Strawn 2014a; M. T. Hoffman 2011). However, the percentage of psychotherapists in the United States who endorse psychoanalytic therapy as their primary theoretical orientation is still small, about 3 percent of clinical psychologists, 1 percent of counseling psychologists, 5 percent of social workers, and 2 percent of counselors (Prochaska & Norcross 2018, 3). More of them endorsed broad-based psychodynamic therapy as their primary theoretical orientation: about 15 percent of clinical psychologists, 9 percent of counseling psychologists, 9 percent of social workers, and 5 percent of counselors (Prochaska & Norcross 2018, 3). Psychoanalytic therapy or psychodynamic therapy has also received more substantial empirical support for its efficacy for a range of psychological disorders and can be considered an empirically supported treatment (e.g., see Leichsenring, Leweke, et al. 2015). Further empirical research on psychoanalytic and psychodynamic therapy will be conducted in the years to come.

Several crucial modifications to traditional Freudian theory have been made in recent years. As noted earlier, the therapeutic relationship in psychoanalytic therapy is now more often viewed as mutual and interpersonal. There is also more openness to and integration of other psychotherapy approaches, such as humanistic and cognitive therapies, as well as the integration of neuroscience and psychoanalysis, called neuropsychoanalysis (Prochaska & Norcross 2018; see also E. B. Luborsky, O’Reilly-Landry, & Arlow 2008). Relational theory has been further developed and refined so that relational psychoanalytic concepts can be integrated with other psychotherapeutic approaches, including cognitive-behavioral therapies (Wachtel 2008). More recently, the core competencies of relational psychoanalysis have been described in a guide to practice, study, and research (Barsness 2018).

Traditional or classical psychoanalysis is being provided to less than 1 percent of all clients receiving counseling or psychotherapy today. It has become less important as relatively shorter-term versions of relational psychoanalysis and time-limited psychoanalytic therapy (e.g., see Levenson 2017; McWilliams 2004, 2011; Summers & Barber 2010) are now more widespread and popular (Prochaska & Norcross 2018). A specific development in this context is the use of treatment manuals that provide detailed instruction for conducting time-limited psychoanalytic or more broad-based psychodynamic therapy (Sharf 2016). For example, the Core Conflictual Relationship Theme method developed by Lester Luborsky and his colleagues has been described in detail in treatment manuals (Book 1998; L. Luborsky 1984; L. Luborsky & Crits-Christoph 1998). This method is a sixteen-session model for conducting brief psychodynamic or psychoanalytic therapy. The therapist focuses on relationships that the client brings up, clarifying the client’s wish, a response from the other, and a response from the client. The therapist makes carefully timed interpretations of client transference, reflecting the client’s attitudes and behaviors from past, early relationships that still influence current relationships with others, including the relationship with the therapist (see Sharf 2016, 64–65). Attachment theory has also become an important part of contemporary psychoanalysis and psychoanalytic therapy (e.g., see Eagle 2013; Fonagy 2001; Wallin 2007). Several attachment-based therapies that have received some empirical support for their efficacy include interpersonal psychotherapy, emotionally focused therapy, mentalization-based treatment, supportive psychodynamic therapy, and transference focused therapy (see K. N. Levy & Johnson 2019).

Despite these current changes and future directions of psychoanalysis and psychoanalytic therapy, several important concepts from Freud are still valued today, based on substantial empirical and clinical support. They include the importance of the unconscious; the crucial role of childhood traumas and experiences in the development of behavioral problems; the pervasiveness of inner conflict in the lives of human beings, who must then devise compromise solutions; and the powerful impact that mental representations of self, others, and relationships have on the current functioning of individuals (Westen 1998).

Formal training to be a psychoanalyst usually requires a minimum of four years of coursework, after one obtains a doctoral degree (PhD or PsyD) in clinical psychology or completes a psychiatry residency and is admitted into a psychoanalytic institute of training. Some institutes also admit social workers in clinical practice. The formal training includes the personal analysis of the candidate in training by a senior psychoanalyst, as well as supervised treatment of analysands or clients seen by the candidate three to five times a week for a few years. The American Psychoanalytic Association (www.apsa.org), founded in 1911 and part of the International Psychoanalytical Association, is the largest psychoanalytic society in the United States. Division 39, the Division of Psychoanalysis of the American Psychological Association, had a list of ninety-two training programs in psychoanalysis. Many psychoanalytic journals are also being published, including the International Journal of Psychoanalysis and the American Journal of Psychoanalysis (E. B. Luborsky, O’Reilly-Landry, & Arlow 2008, 28–29). Psychoanalysis and especially psychoanalytic therapy (that is more relational and attachment-based) will therefore continue to be a significant part of contemporary counseling and psychotherapy, with some even stating that psychoanalysis is actually flourishing and thriving (e.g., see Sharf 2016, 66).

Recommended Readings

In addition to Freud’s own works (a total of twenty-four volumes of the Standard Edition published by Hogarth Press in London), the following books are recommended for further reading:

Bland, E. A., & Strawn, B. D. (Eds.). (2014). Christianity and psychoanalysis: A new conversation. Downers Grove, IL: IVP Academic.

Brenner, C. (1974). An elementary textbook of psychoanalysis (Rev. ed.). Garden City, NY: Doubleday.

Eagle, M. N. (2013). Attachment and psychoanalysis: Theory, research and clinical applications. New York: Guilford.

Gabbard, G. O. (2010). Long-term psychodynamic psychotherapy: A basic text. Washington, DC: American Psychiatric Association.

Gabbard, G. O., Litowitz, B. E., & Williams, P. (2012). Textbook of psychoanalysis (2nd ed.). Washington, DC: American Psychiatric Association.

Hall, C. S. (1999). A primer of Freudian psychology. New York: Meridian.

Jones, E. (1961). The life and work of Sigmund Freud (Abridged ed.). New York: Basic Books.

Levenson, H. (2017). Brief dynamic therapy (2nd ed.). Washington DC: American Psychological Association.

McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide. New York: Guilford.

Mitchell, S. A. (2000). Relationality: From attachment to intersubjectivity. Hillsdale, NJ: Analytic Press.

St. Clair, M., & Wigren, J. (2004). Object relations and self psychology: An introduction (4th ed.). Belmont, CA: Brooks/Cole.

Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based practice. New York: Guilford.

Wallin, D. J. (2007). Attachment in psychotherapy. New York: Guilford.

Chapters 5

Adlerian Therapy

Alfred Adler (1870–1937), the founder of individual psychology (Adlerian therapy), was originally part of the inner circle of Sigmund Freud’s Vienna Psychoanalytic Society and even served as its president and editor of its journal. However, Adler had substantial disagreements with many of Freud’s psychoanalytic views, which Freud could not tolerate. Adler therefore parted ways with Freud in 1911, founding his own school of therapy as well as a new society and journal. Individual psychology, or Adlerian therapy, emphasizes social motivation and subjective perception more than sexual drives in human behavior. In particular, Adler was much less deterministic and more optimistic in his view of human nature. He focused more on the significant influence of life goals on behavior, the crucial role of a basic striving for superiority in every individual, the importance of social interest and connecting with the community, the effects of birth order, and especially the substantial influence of a person’s core assumptions and beliefs (erroneous or valid) about their lifestyle, with some freedom of choice (Corey 2021).

Adler’s great impact on contemporary counseling and psychotherapy is not limited to his own individual psychology or Adlerian therapy school. His theoretical ideas and therapeutic techniques have significantly influenced so-called neo-Freudians such as Karen Horney and Erich Fromm, as well as founders of other schools of therapy like Carl Rogers and Albert Ellis, as well as Viktor Frankl and Rollo May. He also helped to popularize his ideas for the general public, who often associate Adler with the concept of the inferiority complex.

Biographical Sketch of Alfred Adler

Alfred Adler was born on February 7, 1870, in a small Austrian village near Vienna. He was the second son (and third child) in a family of six children with Hungarian-Jewish parents. He grew up in an ethnically diverse neighborhood and was more Viennese than Jewish in his identity. He became a Protestant when he was thirty-four years old.

Adler had an unhappy early childhood, filled with emotionally painful experiences and various serious illnesses, including a brush with death due to pneumonia when he was five years old. Two years earlier, when Adler was three years old, a younger brother died in a bed next to him. Adler himself was seriously injured in a couple of bad street accidents near his home. His older brother was very successful and talented, and Adler was deeply envious of him and felt inferior to him. Adler did not do well academically as a young child, so much so that his teacher advised his father to apprentice him to a shoemaker so that he could learn a trade rather than continue in school. However, his father ignored this teacher’s advice and instead encouraged Adler to pursue further schooling. Adler did so and ultimately did well academically. He chose to study medicine at the University of Vienna and graduated with his medical degree in 1895. His childhood experiences obviously had a strong effect on his subsequent ideas, such as those regarding inferiority and the inferiority complex and the basic striving for superiority or mastery and perfection.

Adler married Raissa Epstein in 1897, and they had four children, two of whom also pursued careers in psychiatry and psychotherapy. His wife, who was from Russia, was seriously committed to socialism and feminism. She had a significant influence on Adler and his emphasis on the equality of women and men.

In 1898 Adler began his private practice as an ophthalmologist but changed to general practice. Later, he specialized in neurology and psychiatry. As a practicing psychiatrist, he took a keen interest in the whole person, paying attention to the psychological, social, and physical aspects of an individual’s life.

In 1902 Freud invited Adler to become part of the psychoanalytic group that Freud was forming at the time. Adler was one of the four original members of the group, and in 1910 he succeeded Freud as president of the Vienna Psychoanalytic Society. However, he had serious disagreements with many of Freud’s ideas, especially with Freud’s emphasis on sexual drives. Adler focused more on social motivations and subjective perceptions in explaining human behavior. He also did not undergo psychoanalysis for himself. Freud was unable to tolerate Adler’s significant differences with him, and Adler parted ways with Freud in 1911. Adler founded the Society for Free Psychoanalytic Research or Investigation, which was later renamed the Society for Individual Psychology, and in 1914 he and a colleague launched the Journal of Individual Psychology.

Adler interrupted his theoretical work to serve as a medical officer in the Austrian army during World War I. After the war, he demonstrated his social interest, especially in children, by establishing over thirty child guidance clinics in the Vienna school system. He also began training other professionals to use his ideas and the techniques of individual psychology, which focused on the whole individual. Adler advocated for school reforms and better child-rearing practices and spoke out against prejudices that were responsible for conflict.

Adler also wrote for the general public and was able to popularize his ideas and the methods of individual psychology. His book Understanding Human Nature (1959) became a widely read bestseller in the United States.

Adler first visited the United States in 1926 and later made many trips to lecture in the United States and other countries. In 1935 he and his wife moved to New York, where he held a faculty position at Long Island College of Medicine. Adler kept a very busy, grueling schedule. Although his friends urged him to slow down, Adler ignored their warnings. He died of a heart attack on May 28, 1937, in Aberdeen, Scotland, during a lecture tour. After Adler’s death, Rudolph Dreikurs played a major role in the expansion of individual psychology in the United States.

For further information on Adler’s life and work, see Bottome (1957), Orgler (1963), Rattner (1983), E. Hoffman (1994), Mosak and Maniacci (1999), J. Carlson, Watts, and Maniacci (2006), J. Carlson and Maniacci (2012), J. Carlson and Englar-Carlson (2017), Sweeney (2019), and Sperry and Binensztok (2019).

Major Theoretical Ideas of Adlerian Therapy

Perspective on Human Nature

Adler’s perspective on human nature was much less pessimistic and deterministic and more optimistic than Freud’s view. Adler emphasized the individual’s freedom to responsibly choose life goals and purpose in life, which can guide one’s life and lifestyle. He has therefore been considered a forerunner to the existential school of therapy by existential therapists such as May and Frankl, who also emphasized one’s freedom to choose and be fully responsible for one’s own life. Although Adler acknowledged that a person’s basic approach to life is already formed within the first six years of childhood, he focused more on one’s interpretation of the meaning of early childhood experiences and a longing for social connectedness as crucial motivations of human behavior. Adler also emphasized the teleological, or goal-oriented, nature of human beings, focusing on conscious choice more than the unconscious, in seeking fulfillment and meaning in life.

A major aspect of Adler’s theory is his description of inferiority feelings, which are seen as normal, occurring in every human person. Every individual has some area of deficiency that will lead to feelings of inferiority. To compensate for such feelings, however, a person will be motivated to strive for mastery, competence, or success: a basic striving for “superiority” or perfection, but not necessarily in an arrogant way. Adler was therefore basically optimistic in his view of human beings as capable of positive compensation for inferiority with a creative striving for superiority.

Adler also emphasized the whole person or total personality of an individual, with attention to all aspects of functioning, including the social and systemic context and the psychological and physical dimensions. He called his approach to therapy individual psychology to emphasize that it focused on the whole person in social context instead of being reductionistic and narrowly attending to only the internal psychological or biological aspects of the individual.

The major theoretical ideas of Adlerian therapy are subjective perception or interpretation of reality; unity and holistic development of personality (including goal-oriented and purposeful behavior, inferiority and a basic striving for superiority, and the lifestyle of an individual); social interest and community feeling; the life tasks; and birth order (see Corey 2021, 99–104).

Subjective Perception of Reality

Adlerians take a phenomenological approach to understanding their clients by focusing on how a client perceives or interprets reality and gives meaning to personal experiences. In other words, the crucial element is a client’s subjective experience of reality in terms of their own perceptions, interpretations, assumptions, beliefs, values, thoughts, and feelings, not some objective reality out there. This subjective, phenomenological view of the client’s experience of reality as a major influence on human behavior is a key concept not only in Adlerian therapy but also in many other contemporary approaches to counseling and therapy, such as existential therapy, reality therapy, cognitive behavior therapy, rational emotive behavior therapy, solution-focused brief therapy, family therapy, and feminist therapy (Corey 2021, 125). Eventually attempts have been made to integrate Adlerian therapy with cognitive and constructive therapies (R. Watts 2003).

Unity and Holistic Development of Personality

Adler viewed human personality holistically, with the individual developing in a unified way by self-selecting a basic life goal formed in the context of the person’s unique life experiences as well as specific family, social, and cultural environments. The interpersonal relationships in the social context of an individual are considered in Adlerian therapy much more than the person’s internal or psychological dynamics.

Three major concepts in Adlerian therapy relating to human personality development in a holistic way are goal-oriented and purposeful behavior, inferiority and a basic striving for superiority, and lifestyle.

Goal-Oriented and Purposeful Behavior

In addition to Freud, with whom he increasingly disagreed over time, Adler was also influenced by several significant historical figures, including Pierre Janet, who asserted that the general reason for neurosis is an underlying sense of inferiority; Friedrich Nietzsche, who stressed the central significance of the individual as well as the striving for perfection; Karl Marx and his ideas on socialism and social forces as the major influence on human behavior; and especially Hans Vaihinger, a philosopher who wrote The Psychology of “As If” (1911), emphasizing that people form their own perceptions of truth or reality and live by their own self-selected purposes and fictional goals (Parrott 2003).

Adlerians therefore view human behavior as being goal oriented and purposeful, motivated more by future goals than past experiences, a teleological explanation rather than a deterministic one. Fictional finalism is a term often used by Adlerians to refer to a self-selected, imagined life goal that influences an individual’s behavior and actions. However, Adler himself eventually replaced this term with others such as “goal of perfection” or “guiding self-ideal” to refer to a person’s basic striving for mastery or superiority (R. E. Watts & Holden 1994). Clients can choose their own subjective life goal, which will help them to act in ways consistent with it and to perceive and interpret their experiences accordingly.

Inferiority and Striving for Superiority

Adler assumed that fundamental feelings of inferiority and the need for their compensation expressed in a basic striving for superiority or perfection or completion are innate in all human beings. Earlier he had written about organ inferiority, referring to physical defects or personality deficiencies, in the causation of neurosis (1917). However, Adler was optimistic that human beings can compensate for their feelings of inferiority originating in childhood by striving for superiority, competence, and mastery, resulting often in creative and successful achievements in life.

Nevertheless, feelings of inferiority can become abnormal when they form an inferiority complex, in which an individual appears to self and to others as someone unable to solve a problem in a socially useful way (Ansbacher & Ansbacher 1956). Abnormal feelings of inferiority can also result in a superiority complex, whereby a person appears to self and to others as someone who is capable and strong, but the external appearance of self-importance and inflated self-confidence actually mask deep and abnormal feelings of inferiority (Sharf 2016).

Lifestyle

A person’s lifestyle in the Adlerian context refers to a plan for living or a style of life based on one’s fundamental beliefs, a lifestyle that pulls together reality for the person and lends meaning to life experiences. One’s lifestyle is thus the typical way that one lives or moves toward a self-selected life goal. Adlerians view people as proactive participants in life and society. Although they believe that an individual’s life goal is mainly set within the first six years of life, they also believe one can still correct faulty or invalid assumptions and beliefs and consciously choose a more appropriate life goal based on more accurate and valid assumptions and beliefs and hence a new lifestyle guided by the revised life goal (Corey 2021).

Social Interest and Community Feeling

Adler’s ideas about social interest and community feeling may be his most unique and important theoretical contributions to individual psychology (Ansbacher 1992). Social interest refers to a person’s sense of empathy and identification with others and interest in achieving a better future for all humanity. Social interest is usually demonstrated through shared social activities with respect for others. Adler viewed social interest as a crucial characteristic of mental health. Community feeling is closely associated with social interest and refers to a sense of belonging and social connectedness with others in the contexts of family and society and the world (Corey 2021).

The Life Tasks

Adler described the following three universal life tasks that everyone seeks to successfully accomplish: (1) the social task of building friendships; (2) the love-marriage task of achieving intimacy; and (3) the occupational task of work, making significant contributions to society (see Dreikurs & Mosak 1966). Three other life tasks that Adlerians have added are these: (4) the self-acceptance task of learning to get along with oneself (Dreikurs & Mosak 1967); (5) the development-of-spirituality task, which involves growing in one’s life goals, meaning, values, and relationship with the universe (Mosak & Dreikurs 1967); and (6) the parenting and family task (Dinkmeyer, Dinkmeyer, & Sperry 1987).

Birth Order

Adler viewed birth order and sibling relationships as another crucial factor influencing a person’s social relationships and lifestyle. He emphasized that the psychological, or perceived, birth order of the child is more significant than the actual, chronological, birth order. He provided possible influences of birth order on the oldest child (who is treated like an only child, with some pampering, until the next child comes along), the second child (who must share attention with another child, often with some competitive struggle), the middle child (who often feels forgotten or squeezed out and can be a problem child or a peacemaker), the youngest child (who tends to be the most pampered child), and the only child (who is often pampered by parents and may have trouble sharing with others) (see Corey 2021, 103–104). Adlerians often criticize birth-order research that focuses only on actual position or birth order in the family. A good example that illustrates the need to look more at the psychological birth order rather than simply at actual birth order in a family is provided by Sharf, using the model of a family with three children, in which the first child is one year older than the second (or middle child), who in turn is twelve years older than the youngest (or third child). Adlerian therapists may approach this specific family as consisting of two subsystems: the first as a family with a younger and an older sibling (the first two children), and the second as a family with an only child, with the youngest child viewed more like an only child (2016, 132).

Therapeutic Process and Relationship

In helping their clients, Adlerian therapists use a model that is more psychoeducational than medical. They do not view their clients as mentally ill and in need of a cure. Instead, Adlerian therapists believe that the major problem for their clients is that they are discouraged in dealing with problems and struggles in living. Encouragement is therefore the most important therapeutic method employed in Adlerian therapy, which also involves directly informing, teaching, and guiding clients to help them change their faulty assumptions and the mistaken goals in their private logic or thinking, so that they can be reeducated to live more on the useful rather than the useless side of life. Clients will then experience more social interest and community feeling, with greater courage and self-confidence to live this way.

The therapeutic relationship between the Adlerian therapist and the client is a warm and collaborative one: they can work together to make the changes necessary for the client to live a more meaningful and fulfilling life. The Adlerian therapist focuses on strongly encouraging and affirming the client, in order to counter the significant discouragement that often brings clients into therapy in the first place. The Adlerian therapist is therefore active and directive, but also very empathic, supportive, and encouraging. The client needs to be open and willing to disclose personal and family information. For example, the Adlerian therapist will use a questionnaire to assess the client’s family constellation: relationships and experiences with parents, siblings, and others who are living with the client at home. The therapist will also ask the client to provide early recollections, memories of specific events in childhood that the client is able to reexperience, in order to further assess how the client views self and others, as well as envisioning the future. The Adlerian therapist uses such methods to assess the client’s lifestyle, so that clearer goals for therapy can be collaboratively set. Adlerian therapy tends to be relatively short term, usually lasting from several months to a year or so.

Some of Adlerian therapy’s main psychoeducational goals for the client include fostering social interest, countering discouragement, reducing feelings of inferiority, and modifying faulty assumptions and mistaken goals—that is, changing a person’s lifestyle, changing faulty motivation and values, encouraging an individual to have a sense of equality with others, and helping the client to become a productive member of society (see Mosak & Maniacci 2008, 79).

Major Therapeutic Techniques and Interventions

Adlerian therapy is usually conducted in the following flexible and sometimes overlapping phases (Dreikurs 1967):

Establishing a therapeutic relationship

Conducting an assessment of the client’s dynamics

Providing insight and interpretation

Facilitating reorientation and reeducation

More-specific therapeutic techniques and interventions in each of these four major phases of Adlerian therapy are here briefly described. Adlerian therapists are quite pragmatic and eclectic in the specific therapeutic techniques they use to help clients achieve their therapeutic goals (e.g., see J. Carlson & Englar-Carlson 2017; Sperry & Binensztok 2019; Sweeney 2019).

Establishing a Therapeutic Relationship

The Adlerian therapist works at forming a warm, empathic, and collaborative relationship with the client, based on genuine caring, encouragement, and mutual respect and trust. The therapist does not rush to problem-solve but instead provides much support and understanding to facilitate client exploration and disclosure.

In this first phase of therapy, the Adlerian therapist employs the following therapeutic techniques: listening and attending with deep empathy, sensitively understanding and tracking the client’s subjective experiences as far as possible, clarifying and setting goals, and making tentative interpretations of the possible purposes of the client’s behaviors and symptoms (Corey 2021).

Conducting an Assessment of the Client’s Dynamics

This second phase of Adlerian therapy uses two main types of interview: the subjective interview and the objective interview (Dreikurs 1997). In the subjective interview, the Adlerian therapist, through active and demonstrated deep interest, supports the client in telling their life story as fully as possible. The therapist attempts to identify the purposes and meanings of the client’s life experiences. Toward the end of this subjective interview, the client is often asked whether they have anything else to share with the therapist so that the therapist can better understand the client and their concerns. To further clarify the client’s problems and goals, Adlerian therapists often end the subjective interview by asking “The Question”: “How would your life be different, and what would you be doing differently, if you did not have this symptom or problem?” (Corey 2021, 109). A shorter version of The Question is this: “What would be different if you were well?” (Parrott 2003, 135).

The objective interview seeks to obtain information in the following areas: the history of the client’s problems; precipitating events, if any; medical history, with past and present medication usage; social history; reasons for the client coming to therapy at this specific time; the client’s way of coping and dealing with life tasks; and an assessment of the client’s lifestyle (Corey 2021). Adler conceptualized lifestyle as consisting of four major components: the self-concept, the view of oneself based on reality; the self-ideal, the view of oneself as one would like to be; the picture of the world, one’s view of the reasons for things working the way they do in the external world; and one’s ethical convictions. This lifestyle, meaning basic strategy or map for living, influences one’s choices and behaviors. There are three major “entrance gates to mental life” that Adlerian therapists explore with clients in order to assess and better understand their lifestyles: birth order and the family constellation, early recollections or memories, and dreams (Parrott 2003).

Birth Order and Family Constellation. Birth order, or perceived psychological birth order, is an important part of the assessment of the client’s family background and experiences or family constellation. With the client, the Adlerian therapist explores not only the client’s birth order, but also experiences with the mother and father, siblings, and others in the family; the marital relationship between the client’s parents, including how they dealt with conflicts; and the disciplinary methods they used with the children. Adler viewed such family-of-origin experiences as having a crucial effect on the personality development of an individual. Early Recollections or Memories. Adler emphasized the crucial significance of a person’s earliest memories or recollections of specific, clear events, especially in childhood, for understanding the client’s present lifestyle or current view of life. The Adlerian therapist often guides a client in recalling such early memories or recollections: “I would like to hear about your early memories. Think back to when you were very young, as early as you can remember (before the age of ten), and tell me something that happened one time” (Corey 2021, 111). In a shorter version of this request, the therapist says: “Think as far back as you can and tell me your earliest memory from your childhood years” (Parrott 2003, 126). The therapist will ask for more details about a specific recollection and not settle for vague, general memories. Clients often provide several specific early recollections, which the Adlerian therapist will record in order to identify possible themes that may be connected to the client’s current lifestyle or view of life.

Dreams. Adler viewed dreams not as wish fulfillments (as Freud did) but as an individual’s attempts to deal with future difficulties. The moods or emotions experienced in a dream may also be related to the next day’s anticipated events. Adler further interpreted dreams as possible reflections of progress (or the lack of it) in Adlerian therapy. He noted that dreams may become more active as therapy progresses more successfully and the client makes more therapeutic changes in life and lifestyle. Dreams can therefore be used—in conjunction with family constellation, including birth order, and early recollections or memories—to assess a client’s lifestyle in Adlerian therapy.

In addition to these three major ways of lifestyle assessment, Adlerian therapists may also use two others: assessment of a client’s basic mistakes and assets (Sharf 2016, 138–139). Basic mistakes are based on early recollections and refer to the negative, self-defeating aspects of a client’s lifestyle. Harold Mosak and Michael Maniacci (2008, 82) describe five categories of basic mistakes:

Overgeneralizations, for example, “Life is dangerous.”

False or impossible goals of security, for example, “I have to please everybody.”

Misperceptions of life and life’s demands, for example, “Life is so hard.”

Minimization or denial of one’s worth, for example, “I am stupid.”

Faulty values, for example, “Be first even if you have to climb over others.”

Identifying basic mistakes can be helpful in assessing a client’s lifestyle, but correcting or modifying such mistakes in thinking or worldview is more difficult because a client may not be consciously aware of making basic mistakes in thinking.

The assessment of assets involves focusing on what is good and positive in a client rather than on what is deficient and negative. In assessing and identifying a client’s assets, such as academic skills, athletic abilities, or integrity, Adlerian therapists can provide strong encouragement to a client by giving direct and affirming feedback about their specific strengths. Sweeney (2019) has therefore emphasized a wellness approach to Adlerian therapy, with scales to measure wellness, and recently integrated it more with neuroscience. Maniacci and Laurie Sackett-Maniacci (2019) have pointed out how Adlerian therapy actually is closely related to contemporary positive psychology (e.g., see M. E. P. Seligman 2011) in emphasizing the assets and strengths of clients, but positive psychology hardly acknowledges Adler and his ideas (see also Mozdzierz 2015).

Providing Insight and Interpretation

In this third phase, Adlerian therapists proceed to interpret material collected in the process of lifestyle assessment in order to facilitate the client’s self-understanding or insight into personal behavior. In Adlerian therapy, the therapist makes interpretations only with regard to the client’s goals and purposes, and not about the internal psychological dynamics (Dreikurs 1967).

Interpretations are provided in a tentative and well-timed manner, so that clients are less likely to react in a defensive way or with resistance. Adlerian therapists often present an interpretation in the form of a tentative suggestion or question, using statements such as “I wonder if . . . ,” “It seems to me that . . . ,” and “Could it be that . . . ?” Clients are more likely to accept interpretations phrased in this sensitive and tentative style and thus develop deeper insight and self-understanding into the purposes and goals of their current functioning as well as dysfunctioning, including symptoms. They may also discover how they can go about changing or correcting their basic mistakes in thinking or in their private logic and in their mistaken goals.

Facilitating Reorientation and Reeducation

The last phase of Adlerian therapy is action oriented and focuses on facilitating the client’s reorientation and reeducation or helping the client to translate insights into actions. Adlerian therapists employ several therapeutic techniques to do this, but the crucial intervention is the use of encouragement. Clients are encouraged as well as challenged to take courageous steps and risks to bring about constructive and positive changes in their lives.

Some clients may need to make enormous changes, but many clients need only to be reoriented to what is called the useful side of life. This term refers to several characteristics such as courage, being valued, having a sense of belonging and connectedness with the community, caring for others and their well-being, embracing imperfection, gaining confidence, a sense of humor, a willingness to contribute, and friendliness that is shown outwardly. In contrast, the useless side of life involves self-protection and self-absorption, avoiding engagement in life tasks, and committing negative acts against other people (Corey 2021, 113–114). Adlerian therapy seeks to help clients move from the useless side of life, which is associated with less functionality and more psychopathology, to the useful side of life.

The following are the main therapeutic techniques used in Adlerian therapy to facilitate reorientation and reeducation in clients: encouragement, immediacy, acting “as if,” catching oneself, creating images, spitting in the client’s soup, avoiding the tar baby, push-button technique, paradoxical intention, task setting and commitment, homework, life tasks and therapy, and terminating and summarizing the interview (see Sharf 2016, 140–145; also Bitter et al. 1998; Bitter & Nicoll 2000; J. Carlson, Watts, & Maniacci 2006; Dinkmeyer & Sperry 2000).

Encouragement. Encouragement is the most significant and unique therapeutic technique used by Adlerian therapists to support and affirm clients, as an antidote to their discouragement in life. Encouragement is especially crucial in helping clients to believe that they can make the changes they want and need to make and then to take action and even risks toward therapeutic and constructive change. Encouragement does not consist only of comments such as “Keep on trying; I know that you are capable of doing this.” Adlerian therapists use creativity and deep caring, as well as courage, to strongly affirm and support their clients.

Adler himself was once confronted by a young woman suffering from schizophrenia. Even though she physically hit him, he responded with friendliness instead of retaliation. He did this to encourage and affirm her, which led to her renewed courage. She then broke his glass window and cut her hand as a result. Instead of locking her in her room, Adler bandaged her hand without reproaching her and again engaged in creatively and courageously encouraging her. She responded well to Adler and these therapeutic interventions (see Ansbacher & Ansbacher 1956, 316–317, cited in Sharf 2016, 141).

Immediacy. With this technique, an Adlerian therapist comments on what the therapist is presently experiencing with the client in the actual therapy session as it is unfolding. It may involve verbal or nonverbal communication by the client that somehow relates to the therapy goals already agreed upon with the therapist. The therapist will make an immediacy response or comment in a tentative way and will often ask a question at the end of the comment such as “Is that right?” or “Is this correct?” This process will help the client to be more open and less defensive so that they can respond to the therapist’s immediacy expression by further exploring what may be blocking the achievement of therapeutic goals.

Acting “As If.” In this technique, the Adlerian therapist asks clients to act “as if” they are capable of executing or doing certain actions that they are afraid to try, and to actually do them as a homework assignment in the week ahead. For example, a very shy client may be encouraged by the therapist to act “as if” they were a confident person and to try to be assertive at work by asking the boss for a long-overdue pay raise. The therapist may also role-play this behavior in the therapy session with the client before the client attempts it in real life in the coming week.

Catching Oneself. The technique of “catching oneself” involves instructing clients to catch themselves just before engaging in negative or problematic behaviors, and therefore to be aware of it in time to change it before it occurs out of habit. Over time, clients may be able to catch themselves just before rather than after engaging in certain self-defeating behaviors and to stop just in time to replace them with more constructive and helpful behaviors.

Creating Images. This technique refers to suggesting that clients visualize an image of themselves doing well or succeeding in a situation that can be difficult or stressful. For example, a usually timid client may be encouraged to imagine being cool and assertive in asking a roommate not to smoke in their room, with the roommate responding well and agreeably (Mosak & Maniacci 2008).

Spitting in the Client’s Soup. This technique’s name is based on a bad habit that children at boarding schools used to practice in order to get another person’s soup by spitting in it. The Adlerian therapist uses this technique by making a comment about a specific client behavior that takes the reward or attraction out of it. For example, a mother may express how much she sacrifices in order to provide for her children. The therapist may then comment on how sad it is that the mother has no time for herself and her own enjoyment of life, thus removing the heroic aspect out of her self-sacrifice.

Avoiding the Tar Baby. Adler used the phrase “tar baby” to refer to an issue that is sticky (tar) or difficult for a client to face. A client may therefore be especially sensitive to how this issue is addressed and be defensive or resistant if the therapist deals with it in an insensitive or confrontational way. For example, a client may feel that colleagues at work tend to ignore him and now wonders if the therapist may also not really be interested in the client’s problems and thus may be ignoring the client. To avoid the tar baby, the Adlerian therapist reassures the client by asking more questions about what is happening in the client’s work situation.

Push-Button Technique. This Adlerian technique described by Mosak (1985) involves asking a client to close their eyes and first imagine a very pleasant memory (such as a beautiful sunset or a success experience) and attend to the positive feelings associated with it. The client is next instructed to imagine a horrible memory (such as the death of a loved one or a failure experience) and attend to the negative feelings associated with it. The third and final part of this technique involves asking the client again to imagine another very pleasant memory or go back to the first pleasant memory and experience the positive feelings associated with it. At the end of this three-part imagery technique, the client opens their eyes and realizes that one can have some control over personal feelings by the thoughts or memories one chooses. The Adlerian therapist therefore helps the client learn this push-button technique: that one can control one’s feelings through the thoughts, memories, or images one chooses, or by the buttons one pushes in one’s mind.

Paradoxical Intention. With this technique, the Adlerian therapist encourages clients to practice and even exaggerate the very symptoms or problematic behaviors troubling them. Adler has described this intervention as “prescribing the symptom.” For example, the therapist will instruct a compulsive hand-washer to wash their hands even more frequently. In so doing, the Adlerian therapist expects the client to find the inappropriate behavior, now exaggerated, to be less attractive and therefore be more likely to stop it or change it.

Task Setting and Commitment. This therapeutic technique involves the Adlerian therapist working closely with a client collaboratively to plan specific steps of action to overcome certain problems or achieve particular goals. The client chooses what the client is willing to do and therefore makes the commitment to perform certain tasks to achieve those goals. The therapist then helps the client to plan and implement the steps needed to accomplish a task that has been broken down to a manageable size, with a greater likelihood of success.

For example, a client who has decided to return to work after taking medical leave to have surgery will be asked by the therapist what specific steps they would take, such as looking at job ads and postings, applying for relevant job openings, going for job interviews, and finally accepting a job offer if appropriate. The therapist encourages the client to focus more on getting good job leads or possibilities first, rather than on getting a job, as the initial task set before the client.

Homework. Adlerian therapists frequently assign homework for clients to complete between sessions, to help clients accomplish the tasks they have chosen to do. The homework needs to be something clear, concrete, and relatively easy. To a client looking for a job, for example, the therapist may suggest contacting a social worker for possible job leads before their next counseling appointment. They can then discuss the job options and plan the next steps for the client to take.

Life Tasks and Therapy. This technique involves the therapist asking the client to rate their level of satisfaction or happiness in certain life-task areas, such as family, work, friends, and community. In doing this, the client may discover issues needing work that were previously unrecognized. This technique can also be helpful in assessing therapeutic change and progress toward achieving the goals of therapy throughout the course of therapy.

Terminating and Summarizing the Interview. This technique involves setting clear time limits for a therapy session so that the therapist ends a session on time with a client (e.g., thirty-minute sessions for a child and forty-five- to fifty-minute sessions for an adult client). The Adlerian therapist will usually summarize the interview at the end of the session with a client and assign appropriate homework.

By now it should be clear that Adlerian therapists use a variety of therapeutic techniques to help their clients. They also freely give appropriate and well-timed advice, suggestions, and direction in the reorientation phase of Adlerian therapy, which is more action-oriented, after insight and interpretation have already been provided. Helpful advice is therefore seen as an appropriate therapeutic intervention in Adlerian therapy (see J. Sommers-Flanagan & Sommers-Flanagan 2018, 78).

Adlerian Therapy in Practice

This hypothetical transcript of a small part of an Adlerian therapy session demonstrates the therapist’s use of several Adlerian therapeutic techniques: such as asking “The Question,” acting “as if,” and judiciously but clearly providing encouragement, suggestions, and some direction for the client. The therapist is also beginning to formulate homework for the client, in collaborative planning with the client.

Client: I’m feeling tired and lethargic, . . . like I have no energy to do anything, and I don’t feel like doing anything. . . . I guess I’m feeling depressed again . . . and stuck, with no real meaning or direction in my life.

Adlerian Therapist: You’re feeling down and fatigued again, as well as somewhat lost and aimless in your life. What would be different if you were well?

Client: If I were well and not so tired out and depressed and aimless? Well, . . . I am tired of being so tired and depressed! It would be nice to be well again. . . . I guess if I were well, I would of course feel better and want to do more things like I used to . . .

Adlerian Therapist: What things would you do more of, if you were feeling better, if you were well?

Client: I guess I would go bowling more often, something I used to enjoy so much that I belonged to a bowling team and played in bowling leagues. That was years ago. . . . I just don’t have the interest or energy to do this anymore. If I were well, I would also be more involved in community service, such as tutoring inner-city kids in math and English, which I did for a couple of months some time ago. I would also take up painting again, as a hobby . . .

Adlerian Therapist: Great! Sounds like you actually do have several enjoyable and fulfilling activities you would like to do if you were well, like bowling, tutoring, and painting. I actually believe that you can begin to take small, baby steps to do some of these things, to act “as if” you were better or almost well again. . . . What do you think?

Client: I’m not sure. . . . This constant fatigue really drags me down. My doctor has done all kinds of tests and not found anything physically wrong with me. However, I do feel a little hope and interest as I think of myself being well and doing some of these things such as bowling and painting. . . . The tutoring is a bit more difficult for me at this time. So, are you asking me to act as if I were better or almost well and perhaps start a bit of painting again?

Adlerian Therapist: Yes, you’re getting the hang of it, that if you begin to act as if you were better or almost well, you may be able to actually do some of these meaningful and enjoyable activities you mentioned. Your idea of starting to do some simple painting again sounds great, and I’m wondering if you can tell me more how you plan to go about trying to accomplish this in the coming week.

Critique of Adlerian Therapy: Strengths and Weaknesses

Adler’s theoretical ideas and therapeutic techniques were far ahead of his time and have had a pervasive and significant influence on the entire field of counseling and psychotherapy. His emphases on how one’s thinking significantly affects one’s feelings and behavior, how one’s future goals and current values influence one’s life, how one can choose to change a personal lifestyle, and how one is motivated by social factors such as social interest and community feeling—these emphases have all greatly impacted other schools or approaches to counseling and psychotherapy, yet often without acknowledgment to Adler (Ellenberger 1970). However, Albert Ellis did acknowledge Adler as the “true father of modern psychotherapy” (1970, 11).

Adlerian therapy has been used to help clients with a wide range of psychological disorders or problems such as anxiety disorders, some affective disorders, personality disorders, conduct disorders, and antisocial disorders (L. Seligman 1986). It has been applied in various settings and with different age groups: with children, parents, adolescents, families, teacher groups, and other social segments. It is therefore a versatile and broadly applicable approach to therapy (Parrott 2003). It has also been applied to education, parent education, couples counseling, family counseling, and group counseling (Corey 2021; see also Sweeney 2019).

Adlerian therapy is also a comprehensive approach that deals with the whole or total person—hence the term “individual psychology,” which emphasizes treating the individual in a holistic or comprehensive way, focusing on the physical, psychological, social, and even spiritual aspects of human life. The emphasis on social motivation makes Adlerian therapy more open and sensitive to social, cultural, and diversity issues, compared to a more traditional Freudian psychoanalytic approach, which tends to focus too much on internal or intrapsychic conflicts and dynamics.

Adler’s emphasis on the equality of women and men has shaped Adlerian therapy to be an egalitarian approach to counseling that can be incorporated more easily within contemporary therapies such as feminist and postmodern approaches.

Adlerian therapy also uses several practical and helpful therapeutic techniques with the clear, overarching therapeutic principle of facilitating encouragement of clients. Some of these counseling interventions are simple and straightforward, based on a more commonsense approach to helping clients. Adlerian therapy also views the judicious provision of advice, suggestion, and direction as therapeutically helpful and valuable. Thus Adlerian techniques can be used not only by counselors or therapists but also by teachers, parents, and the clergy, due to their simplicity and wide applicability.

Finally, Adlerian therapy can be practiced within a time-limited, short-term model of helping clients within several months to a year. This is another strength of the Adlerian approach since effective or efficacious short-term therapies are especially valued by managed care in the current health-care context in the United States.

Adlerian therapy, however, has several weaknesses. First, Adler was not that systematic and thorough in the development and description of his theoretical ideas and therapeutic techniques. Many of his writings and publications consist of lectures he had given. He emphasized teaching and practice more than careful, systematic theory building and clear operationalization and definition of terms used in individual psychology. In fact, even calling his approach “individual psychology” may be misleading since his unique emphasis is on social motivation rather than individual dynamics.

Second, some critics regard Adlerian therapy as somewhat superficial and simplistic since it emphasizes eventual reorientation and reeducation of the client and pays less attention to insight and interpretation, although it does not ignore interpretation and the need to explore early childhood recollections. Adlerian therapy, however, diverges significantly from traditional Freudian psychoanalytic therapy, which focuses mainly on interpretation of unconscious intrapsychic dynamics and conflicts. Thus Adlerian therapy has been criticized by traditional Freudians for not being deep enough.

Third, Adlerian therapy may not be the most appropriate approach for helping clients who need more direct assistance with addressing immediate concerns and stresses, such as poverty, unemployment, and violence. Although Adlerian therapy is more directive and short term than Freudian psychoanalysis, it still requires clients to explore their early recollections and dreams as well as engage in lifestyle assessments.

Finally, Adlerian therapy has not been sufficiently evaluated in well-controlled therapy-outcome studies. Most of the evaluations of Adlerian therapy have been uncontrolled case studies, which can be biased and methodologically flawed. Definitive conclusions about the effectiveness of Adlerian therapy therefore cannot be drawn at this time, although there is a recent emphasis on the need to conduct more and better controlled outcome studies or empirical research on the efficacy of Adlerian therapy (Curlette & Kern 2016).

A Biblical Perspective on Adlerian Therapy

Adler’s view of human nature is more optimistic and less deterministic than that of Freud. Although Adler believed that an individual’s basic approach to life is formed within the first six years of life, he allowed for change to occur through a person’s freedom to choose new goals and new ways of thinking and perceiving reality. His more positive view of human nature, emphasizing choice and the possibility of change, is somewhat consistent with the biblical view, which also emphasizes the need to choose (cf. Deut. 30:19; Josh. 24:15). However, Adler’s view may be too optimistic or positive, paying insufficient attention to the darker side of human nature as fallen and sinful (Jer. 17:9; Rom. 3:23) and in need of redemption and salvation through Jesus Christ (Rom. 6:23; 2 Cor. 5:17).

Adler’s focus on how future goals can motivate and direct a person’s behavior is a good corrective to Freud’s overemphasis on the deterministic influence of early childhood and past experiences on an individual’s personality and current functioning. It is also more consistent with a biblical perspective that is future oriented, viewing Christ’s second coming or heaven and eternal realities as crucial motivational goals that Christians look forward to, in a way that purifies and positively affects their present behavior and life (see Titus 2:11–14; 1 John 3:2–3).

Adler’s emphasis on the need to identify and correct mistaken goals and basic mistakes in thinking is also consistent with the biblical perspective on the need to be transformed by the renewing of our mind (see Rom. 12:2). One’s thinking does greatly affect one’s feelings and behavior; truthful, biblical thinking is especially crucial from a Christian perspective.

Another aspect of Adlerian theory that is consistent with a biblical perspective is its focus on social interest and community feeling. Adler emphasized the need for every person to be connected with the surrounding community and to contribute to others’ welfare by having a genuine social interest in other people. Scripture also emphasizes the need for other people and connection, not only interpersonally but also spiritually as members of the body of Christ (1 Cor. 12), serving one another with genuine agape love (1 Cor. 13), which is deeper than social interest. The Adlerian idea of social interest is therefore consistent with the Bible’s emphasis on body life and community.

The crucial role of encouragement in Adlerian therapy is another aspect that agrees with the Bible’s emphasis on encouraging one another (see, e.g., 1 Thess. 5:11, 14; Heb. 3:13; 10:25), especially with the spiritual gift of encouragement if one is blessed with it by the Holy Spirit (Rom. 12:8). The spiritual gift of encouragement may be particularly helpful in counseling and people-helping ministries (Tan 1999b).

The reorientation and reeducation phase of Adlerian therapy, which is action oriented, makes it a counseling approach that is more balanced and does not narrowly focus on insight and interpretation of personal, internal dynamics. The Bible similarly emphasizes the need to take steps of faith, to have appropriate works of obedience, because faith, without resulting works, is dead or not true faith at all (James 2:17, 26). Such action steps, however, should still be done in dependence on God and the power of the Holy Spirit, and not simply by self-effort.

Finally, the comprehensive assessment of life tasks in an individual’s life in Adlerian therapy includes the spiritual dimension as an important and valid part of human life. This is a good corrective to Freud’s reductionistic view of religious longings as an obsessional neurosis based on wish fulfillment and longing for a father. However, the Adlerian view of the spiritual dimension is still somewhat vague and generic and does not necessarily refer to God or religious beliefs. The Bible’s view of spirituality is more substantial and specific and ultimately Christ centered, emphasizing our goal to become more like Jesus in authentic Christian spirituality (Rom. 8:29).

Other criticisms of Adlerian therapy can be made from a biblical perspective. The emphasis on being action oriented with the use of some simple techniques to encourage change can be somewhat superficial and simplistic. Although Adlerian therapists do use interpretation to help clients gain insight, it may be necessary to focus on this aspect more and deal with the deeper and darker issues of the human heart, which is fallen and sinful (Jer. 17:9). Another emphasis of Adlerian therapy is the phenomenological or subjective view of one’s perception of reality. This Adlerian view can conflict with the Bible’s view of eternal biblical truth, which is more objective. The Adlerian perspective is actually somewhat contradictory because it does identify mistaken goals and faulty assumptions and delineates several basic mistakes in thinking that assume some objective measure of truth.

Finally, the Adlerian focus on inferiority and the compensatory striving for superiority (perfection or competence) in every individual as a foundational motivation can be problematic from a biblical perspective. Although such compensatory striving for superiority need not be prideful or arrogant, it nevertheless focuses on the human tendency, even if creative, to emphasize strength and mastery in oneself. Pride may very well be present, in subtle if not obvious ways. Even if the striving for superiority does not deteriorate into a more pathological and negative superiority complex, it is nevertheless dangerously close to sinful pride because it focuses on self-achievement and strength in oneself. The Bible’s emphasis on humility (see, e.g., Phil. 2:3–5; 1 Pet. 5:5–6) and how God’s power is made perfect in weakness (2 Cor. 12:9–10) rather than in strength or superiority is not easily reconciled with Adler’s focus on striving for superiority. Ultimately, such striving must be surrendered to the Lord Jesus, who will enable us to experience sufficient grace and strength in weakness so that delightful security and stability in him will replace both feelings of inferiority and the striving for superiority. Our goals will also be directed by God and his will for us, rather than by us setting our own life goals, which may again be mistaken goals.

Research: Empirical Status of Adlerian Therapy

Research on the efficacy or effectiveness of Adlerian therapy has been limited: controlled outcome studies and especially randomized controlled trials have been scarce. However, there are many empirical studies on various aspects of Adlerian theory, such as birth order, lifestyle, and social interest (see Maniacci & Sackett-Maniacci 2019, 86–89; J. Sommers-Flanagan & Sommers-Flanagan 2018, 83, 85), including recent cross-cultural research with participants from Taiwan, Jordan, Iran, Turkey, and Lithuania (see Maniacci & Sackett-Maniacci 2019, 89).

The few previous outcome studies of Adlerian therapy (see M. L. Smith, Glass, & Miller 1980) are not well controlled enough for more definitive conclusions to be made; yet it can be tentatively stated that Adlerian therapy is slightly better than placebo treatment and seems to be as effective as person-centered therapy and psychoanalytic therapy (J. Sommers-Flanagan & Sommers-Flanagan 2018, 83). However, several more-recent outcome studies of Adlerian therapy have been published, but most of them are not well-controlled evaluations (see Maniacci & Sackett-Maniacci 2019, 88; J. Sommers-Flanagan & Sommers-Flanagan 2018, 83, 85).

Adlerian group play therapy has been found to be effective in reducing disruptive classroom behaviors, improving poor social skills, and helping with externalizing behaviors in elementary school students; this is shown in several studies, including a randomized controlled trial with a small sample (n = 58), reported by Kristin Meany-Walen and colleagues (Meany-Walen, Bratton, & Kottman 2014; Meany-Walen, Bullis, et al. 2015; Meany-Walen, Kottman, et al. 2015; Meany-Walen & Teeling 2016).

A recent small Turkish study found positive results of Adlerian encouragement-based group counseling with college students in Turkey (Ergüner-Tekinalp 2017). Adlerian-based parenting programs have also been reported to be effective in many research studies, but they were not randomized controlled trials (e.g., see Burnett 1988; Gfroerer, Kern, & Curlette 2004). Two well-known Adlerian parenting education programs are Active Parenting (Popkin 2014) and Systematic Training for Effective Parenting (Dinkmeyer, McKay, & Dinkmeyer 1997).

Despite these more-recent outcome evaluations tending to support the effectiveness of Adlerian therapy, and especially Adlerian play therapy and parenting programs, there is still an overall lack of controlled outcome research on Adlerian therapy, since Adlerian therapists have preferred the case method, or uncontrolled clinical case studies (Mosak & Maniacci 2008). It is hoped that Adlerian therapy will be subjected to more randomized controlled trials in the near future so that the empirical status for its efficacy can be more solid and substantial (see Curlette & Kern 2016).

Future Directions

Adler has had a great impact on contemporary counseling and psychotherapy. Corey (2021, 125) believes Adler’s influence on current practice is actually greater than that of Freud. It is ironic that the success and popularity of many of his ideas and therapeutic techniques have resulted in their incorporation into other approaches to counseling and therapy, so that the distinctiveness of Adlerian therapy has become more diluted as time has gone by (J. Carlson & Englar-Carlson 2008, 2017). At the same time, Adlerian therapists are also becoming more eclectic in their views and therapeutic practice, incorporating ideas and techniques from other schools of counseling and therapy (R. E. Watts 2003). Adlerian therapy may therefore become less distinctive in the future. However, Mosak and Maniacci (2008) painted a more optimistic picture of the future of Adlerian therapy as that of a respectable, viable, and growing therapeutic system. Maniacci and Sackett-Maniacci (2019, 69) more recently have asserted that Adlerian psychology or therapy shows innovation and progress or forward movement.

An example of an area of innovation in Adlerian therapy is the focus on wellness, referring to the physical, mental, and social well-being of people, and the development of assessment instruments to measure wellness in the work of Thomas Sweeney (2019). A related topic is the Adlerian emphasis on the assets and strengths of clients and how these are closely connected to contemporary positive psychology, with potential for further work in this area (Mozdzierz 2015; R. E. Watts 2012).

There are many loyal practitioners of Adlerian therapy, as well as training institutes and schools, including the Adler School of Professional Psychology in Chicago (www.adler.edu). The Journal of Individual Psychology is published by the North American Society of Adlerian Psychology (www.alfred adler.org), which has around twelve hundred members. Although less than 1 percent of psychotherapists surveyed in the United States indicated Adlerian therapy as their primary theoretical orientation (Prochaska & Norcross 2018, 2–3), the actual number of Adlerian therapists in practice is larger. Adlerians are also better known for their work in educational settings and public schools, therefore with children and families (Sharf 2016). Adlerian therapy will not only survive but even flourish if current practitioners preserve its unique approach, even with further refinements of Adler’s ideas and techniques, and if further controlled outcome research is conducted to establish a stronger empirical base.

Recommended Readings

Adler, A. (1958). What life should mean to you. New York: Capricorn.

Carlson J., & Englar-Carlson, M. (2017). Adlerian psychotherapy. Washington, DC: American Psychological Association.

Carlson, J., & Maniacci, M. P. (Eds.). (2012). Alfred Adler revisited. New York: Routledge.

Carlson, J., Watts, R. E., & Maniacci, M. P. (2006). Adlerian therapy: Theory and practice. Washington, DC: American Psychological Association.

Dinkmeyer, D. C., & Sperry, L. (2000). Counseling and psychotherapy: An integrated individual psychology approach (3rd ed.). Upper Saddle River, NJ: Merrill/Prentice-Hall.

Mosak, H. H., & Maniacci, M. P. (1999). A primer of Adlerian psychology. Philadelphia: Brunner/Mazel.

Sperry, L. & Binensztok, V. (2019). Learning and practicing Adlerian therapy. San Diego, CA: Cognella Academic.

Sweeney, T. J. (2019). Adlerian counseling and psychotherapy: A practitioner’s wellness approach (6th ed.). New York: Routledge.

(Tan, 2022-04-19)

Reference

(Tan, 2022-04-19)

Tan, S. (2022-04-19). Counseling and Psychotherapy, 2nd Edition. [[ VitalSource Bookshelf version]]. Retrieved from vbk://9781493435074