The Evolution of Psychotherapy Since Freud

by E. James Lieberman, M.D.

In 1906, Sigmund Freud (1856-1939), neurologist and first psychoanalyst, hired a young locksmith, Otto Rank (1884-1939), as secretary of the Wednesday Psychological Society--the future Vienna Psychoanalytic Society. Freud, then 50, became a second father to the brilliant, self-taught, working-class youth of who was alienated from his own father, Simon Rosenfeld, an artisan jeweler hot-tempered and given to alcoholic excess.

It was probably Alfred Adler, having read an essay by Rank on the psychology of the artist, who recommended the youth to Freud. Adler, Rank's family physician and a member of Freud's inner circle, recognized the value of Rank's essay, which used the new psychoanalytic theory to create a "sexual psychology of the artist."

Much impressed, Freud hired Rank and sent him back to complete the Gymnasium so he could go on to University. Thus began a 20-year professional and personal relationship between the two men, closer than those between Freud and his sons or Rank and his father. With Freud's help Rank finished his education in six years, becoming the first "lay" or nonmedical analyst. When he obtained his Ph.D. at the University of Vienna in 1912, Rank already occupied an important role at Freud's side as specialist in history, philosophy, art and mythology. Evidence of the esteem in which he was held appears in editions 4 to7 of Die Traumdeutung, Freud's masterwork, where Rank's name appears on the title page as contributor of two chapters in addition to his work as editor and bibliographer.

The year 1913 stands out in the history of psychoanalysis. After the departures of Alfred Adler and Carl Jung over theoretical differences, a Committee, "The Ring," was founded to guide and control the evolution of the new science. Besides Freud himself the members were: Ernest Jones (1879-1958), British biographer of Freud and longtime president of the International Psychoanalytic Association (IPA); Karl Abraham (1877-1925), head of the Berlin Institute for psychoanalytic training; Sandor Ferenczi (1873-1933), the affable, creative intimate of Freud and Rank, from Budapest; Otto Rank, the only one in Vienna with Freud; and, in Berlin, Max Eitingon and lawyer Hanns Sachs (besides Rank the only nonphysician).

The World War blocked communication among the Committee, but the members began to meet and correspond beginning in 1918. The northern axis of the group, London and Berlin, tended to be conservative. Jones and Abraham interpreted psychoanalytic theory narrowly, at times opposing Freud himself, who was flexible and able to change his views. Supporting certain changes, Rank and Ferenczi, the southern axis, elaborated an "active therapy": it made the analyst less isolated--more a partner in exploration than a surgical authority, masked and removed. Besides listening and interpreting, the therapist would guide, support and challenge the patient. Thus began relationship or interpersonal therapy as we know it today.

Freud heartily endorsed the innovation, proposing a prize for the best paper on active therapy in the next IPA Congress (1922). During the next two years disputes raged among the "brethren" under Freud, as the northern and southern contingents strove for Freud's approval and ultimately, his mantle. Jones and Abraham saw a departure from the rigorous science begun by Freud, who in 1912 had written that the ideal analyst would conduct himself as a surgeon, with objective expertise, emotional detachment and authority.

Even Freud did not conduct himself so. In both speaking and writing, he balanced scientific authority with human warmth, charm, humility. These qualities evidently resonated more in Ferenczi and Rank than in Jones and Abraham. Over the years observers have remarked that Freud was less orthodox than his most fervent disciples--beginning, I suggest, with the latter two.

An amusing comment on this phenomenon comes from the pioneer analyst Abraham Kardiner, who was in Vienna with mainly American and British analysts-in-training in the early 1920s. He reported that there was tension between the two groups, the former mostly Jewish, the latter not (Ernest Jones was the only non-Jew on the Committee). One day the British invited the Americans to tea to discuss the different experiences of the two nationalities in working with Freud. The British analysands were perplexed in finding Freud almost totally silent. They had heard that he talked quite freely with at least some of the Americans. Was it true?

Yes. Often Freud would discuss books, theoretical points, even art and politics in the analytic hours.

Apparently the British, not to feel chagrined, concluded that Freud conducted a more serious analysis with them than with their casual, rather motley American counterparts. Kardiner, an immigrant from Europe, heard complaints over the years about long, silent, ineffectual analyses by members of the British school, where "the analyst says nothing except 'good morning' and 'good day.

He added, significantly, that Freud had not conversed with one New Yorker in the Vienna group who was held in lower esteem. Evidently Freud, despite his remark about the surgical attitude, did not hide behind the blank screen of analytic expressionlessness. Those who pleased Freud made him more active. The phenomenon of forthcoming responsiveness is now being taken more seriously by the analytic profession, e.g., in discussions of mirroring, and in renewed interest in the Ferenczi-Rank monograph of 1924, The Development of Psychoanalysis.

The Committee was shaken badly when, at age 67, Freud was afflicted with cancer of the palate. The next year, 1924, fraternal rivalry intensified for heir-apparent. Freud never attended another IPA Congress because of embarrassment or discomfort in speaking and eating due to a prosthesis. But he lived another 16 years, to age 83, enduring repeated operations. He continued to analyze and write, even radically changing his theory about anxiety (Inhibition, Symptom and Anxiety 1926), partly in rebuttal to Rank's Trauma of Birth (1924).

The leadership of the IPA was not elected by the membership, but chosen by the Committee from within. Freud never took the presidency, but approved the decision. Jones, on account of his power in the expanding English-speaking movement, presided for many years; Ferenczi, because of problems in Hungary, stepped down after brief tenure; Abraham died in 1925, and Rank never served, breaking with the movement in 1926. Freud, always afraid that psychoanalysis would be identified as a Jewish science, acceded to Jones although he did not trust the man. Jones and Rank despised each other cordially, and Jones merely gave lip-service to Freud's support of lay analysis. Sachs, Reik, Anna Freud, Melanie Klein, Beata Rank and others--but especially Otto Rank--proved that medical training was not needed to be a good practitioner, theorist or teacher of psychoanalysis.

Ferenczi also fought in the losing battle to keep the IPA open to nonmedical professionals. The active, interpersonal, time-limited therapy which he initially championed with Rank came in response to the Freudian furor after World War I. Physicians and others were lining up to be trained in the new profession, patients were lining up to be treated, writers and critics were taking a new approach to literature, sex was discussed in a new way, and no field was immune to psychoanalytic interpretation. Freud's Introductory Lectures (1917) had been translated into at least seven languages.

According to Ferenczi and Rank, the practice of psychoanalysis had stagnated due to overly strict devotion to theory, and clinical results were too often unsatisfactory. Freud wanted to work out a general psychology more than a method of treatment and he did not presume much about the therapeutic effect of his discoveries. A pessimist, he said that successful psychoanalysis could only transform neurotic misery into ordinary unhappiness. Nevertheless the idea of real help became popular; Ferenczi and Rank firmly held this view and tried to understand and teach its basis.

They criticized the practice of the time for its 1) emphasis on the past; 2) need to uncover--in order to interpret--a basic oedipal complex in every analysand; 3) excessive use of the concept "transference, which concerns the appearance in the analytic situation of a constellation of emotions in the patient toward the therapist, representing unconscious emotions attached to important (parental) figures from the past. Theoretically the process of analysis postulates an inevitable transference neurosis which can be analyzed through profound knowledge of the history, fantasies, dreams and free associations of the patient. But according to the new critique, too many practitioners strove to follow an exact--but nonexistent--Freudian formula. Like Freud, they valued research above helping; at times they imposed inappropriate interpretations about a hidden oedipal complex, and analyzed any resistance until the patient yielded to the truth.

Dr. Clara Thompson, an American psychiatrist whose own analyst was Ferenczi and who analyzed Harry Stack Sullivan, once wrote vividly about the new attitude. She disliked the tendency to analyze everything in relation to parents and the past because, as Rank taught, this diverts attention from the actual relationship.

Rank was the first to point out that in doing this the patient was led away from the living present, at the area of real feeling. As he put it, it is always easier to talk about the past because it is not present. He and Ferenczi stressed, for the first time, that not every attitude toward the analyst is transferred from the past, that there is some reaction to the analyst in his own right, and that it is actually anxiety-relieving and, therefore, stops the progress of analysis, to point out to the patient, You do not really feel this way about me but about your father, etc. Thus, if the patient finally gets the courage to tell the analyst he looks like a pig, the whole issue may be conveniently buried by referring it to the past, saying, That must be what you thought of your father. Two things may happen as a result--the analyst does not have to face the fact that he does look like a pig and the patient feels "I got safely out of that one," but he does not feel more secure thereby because he knows he really meant the analyst and not his father. From that day on he is likely to assume that the analysts' feelings have to be protected. Realizing this, Rank and Ferenczi discovered the importance of the picture of the analyst in his own right--thus transference became more precisely defined as only the irrational attitudes felt and expressed toward the analyst.

Soon Jones and Abraham attacked Ferenczi and Rank. Besides that book, Rank added fuel to the fire with his birth trauma theory, which established the nurturing (pre-oedipal) mother-child relationship as primary in psychological development. At first enthusiastic, Freud gradually aligned himself with the northern axis against the innovators.

In 1924, at age 40, Rank sailed to New York for the summer to analyze and teach. Received warmly as Freud's emissary and then in his own right, his accolades included honorary membership in the American Psychoanalytic Association. Increasingly bitter about the attacks and Freud's withdrawal of support, Rank finally emigrated to Paris in 1926, visiting the United States almost every year until his permanent move there in 1934. He died a month after Freud in 1939, at 55.

Among those who knew Rank and acknowledge his influence are Frederick Allen, pioneer child psychiatrist; Carl Rogers and Jessie Taft, psychologists; and Virginia Robinson, social worker--the last two associated with the Pennsylvania School of Social Work. Many others hid their indebtedness to Rank, since acknowledging him could only hurt them when Freudian psychoanalysis dominated American psychiatry, psychology and social work. In the 20s Rank was one of the most sought after analysts. After 1930, his former analysands were required to undergo reanalysis with a certified Freudian to qualify for IPA membership.

Ferenczi died in 1933, having broken first with Rank and then, in the end, with Freud and the movement. Jones, who completed his massive Freud biography just before his death in 1958, attributed the defections of Rank and Ferenczi to mental illness. This calumny continues to crop up in histories of psychoanalysis, but gradually the writings of these creative pioneers are coming back into the mainstream with the help of interpreters like Leo Stone, John Gedo and Esther Menaker.

Sigmund Freud attempted to secure a scientific basis for knowledge of the psyche belonging previously to poets and philosophers. Regardless of the validity of his theory, he invented a new form of human interaction, the analytic situation. His followers used and modified this invention to its present status, chiefly in psychotherapy, 100 years after the beginning.

With a schematic representation of contrasting emphases, we can look at differences in viewpoint, ideology and practice which characterize the Freudian and divergent--Rankian--psychodynamic systems which now include the interpersonal, existential, client-centered, time-limited and humanistic.

1. Freudian/classical: Science--objective, general

Rankian/modern: Art--subjective, unique

Freud admired artists but considered himself a scientist who worked to validate objectively the intuitions of poets and philosophers. He tried to avoid the appearance of speculative thinking, even denying the influence of Nietzsche. Otto Rank willingly embraced philosophical and artistic sources, and once offered this paradoxical principle: For each patient I need a different theory."

2. F: Analysis, exploration

R: Therapy, helping

Freud borrowed the word analysis (Greek: "separation") from the vocabulary of chemistry. Therapy, on the other hand, derives from the Greek and Latin with meanings of serving, care and healing. Otto Rank, after leaving Freud, used the word "psychotherapy" to describe his work, even alluding to himself as a philosopher of helping. Other pioneers who found a similar path from analysis to helping include Franz Alexander, Karen Horney, Erich Fromm, Frieda Fromm-Reichmann, Harry Stack Sullivan, Sandor Rado, Michael Balint, Erik Erikson and John Bowlby.

3. F: The past, memories, childhood

R: The present, here-and-now

Clara Thompson's statement illustrates this point.

4. F: The unconscious, repression, suppression by the ego

R: The conscious, expression of the ego

If Freud devoted the analytic hour to free that of which one is not aware, Rank used the occasion to confront that which the patient knows but fails to express in words or action.

5. F: Wish, instinct

R: Will, creativity

In psychoanalysis, conscious will has virtually no place; Freud dismissed the will as found in 19th-century psychology. Rank put it back as a central factor, the essence of human identity. Will expresses both ego and instinctual energy. His approach was called "will therapy. This signifies not willfulness but the ability to combine strong goal-directedness with self-discipline and free, spontaneous improvisation.

6. F: Understanding, intellect

R: Experience, emotion

Rank believed that the neurotic suffers precisely because of too much self-analysis, while lacking the courage, on account of guilt and life-fear, to engage in appropriate experience and action. If for Freud (as with Socrates) the unexamined life is not worth living, then with Rank we can say that the uncreative life is not worth living, and the unlived life is not worth examining.

7. F: Transference, interpretation

R: Actual relationship, intimacy

Rankian actuality and existentialism de-emphasizes childhood projection, the kernel of the transference neurosis. Instead, Rank postulates real relationship as the core of therapy, one which (somewhat paradoxically) has a professional kind of intimacy and openness, in contrast with Freud's method in which the analyst keeps removed and unknown.

8. F: Biology

R: Psychology

Freud used the Oedipus myth as a deterministic model of human family dynamics. He argued that every boy unconsciously wishes to kill his father and marry his mother. But Oedipus, an adoptee, loved his psychological parents; of course, he did not know his biological ones because they abandoned him as an infant. Oedipus pursued literal truth over the edge, into tragedy. Knowing who he is" biologically, historically, overcame prudent warnings and Jocasta's petition that he abandon the quest and pursue life. Emotional truth is often not congruent with the factual kind; having relations can mean being related biologically or being intimate. With Jocasta, Rank favored psychological over biological relationship, and he gave philosophical primacy to self-creation over predetermination.

9. F: Death fear

R: Life fear

According to Freud, the patricidal son controls himself for fear of paternal punishment, castration-fear, which symbolizes death. In contrast, Rank sees the problem as one of individuation after involuntary birth. Can we, starting as unwilling newborn creatures, attain a stage in which we embrace our lives, affirming creative will and human responsibility without paralyzing guilt and fear? If so, this signifies a psychological rebirth, the transformation of creature to creator.

10. F: Normality

R: Individuality

According to Rank, the challenge to us in the post-Freudian world is to create an individual personality. In this respect, one who positively engages his/her own will becomes a successful artist, not by painting or composing, but by living according to one's own genius, spirit and limitations. Life is a loan, death the repayment. The creative type invests or spends it; the neurotic, also strong-willed but paralyzed by fear, is a failed artist who (neurotically) tries to deny death: "It can't be all over, I haven't begun to live yet..."

This schematization oversimplifies categories, but may be useful in viewing the forest. It should be clear that Rank, if not the originating source of everything attributed to him, is a major forerunner--largely unacknowledged--of what is now accepted psychotherapeutic theory and practice.

© Psychiatric Times, XIV:4, April 1997, used by permission.
Auf Deutsch: "Trennung und Selbsterschaffung: Leben und Werk von Otto Rank", Psychoanalyse im Widerspruch, 5:56-64, December 1994.
En Esperanto "La Evoluo de Psikoterapio depost Sigmund Freud"
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