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From the very inception of psychoanalysis in the work of Breuer and Freud, analysts have conjectured over how it is that analysis has its therapeutic effect. Why does it work? How does the analytic process bring about psychic change? The usual companion question—does it work—was not seriously addressed by Freud, nor, some would say, has it been addressed since. We will continue in that tradition, taking at face value the evidence of nearly a century of clinical experience that analysis does have therapeutic benefit, well aware of the hazards of equating clinical belief with scientific knowledge, and we will again ask how does analysis work.
Changes in our views on the sources of the therapeutic effectiveness of psychoanalysis have appropriately followed upon changes in psychoanalytic theory and our ideas of the nature of the analytic process. Clearly these changes have been profound and frequent, and a review such as this can only touch on a few major questions. The fullest discussion of the subject would involve us in the entire history of psychoanalytic thought. This review, therefore, will stress only a few high points. A short list of some of the sources of our evolving ideas of change and therapeutic action would include our revised ideas of: