Psychoanalysis

Psychoanalysis is a form of psychotherapy used by qualified psychotherapists to treat patients who have a range of mild to moderate chronic life problems. It is related to a specific body of theories about the relationships between conscious and unconscious mental processes, and should not be used as a synonym for psychotherapy in general. Psychoanalysis is done one-onone with the patient and the analyst; it is not appropriate for group work.

Purpose

Psychoanalysis is the most intensive form of an approach to treatment called psychodynamic therapy. Psychodynamic refers to a view of human personality that results from interactions between conscious and unconscious factors. The purpose of all forms of psychodynamic treatment is to bring unconscious mental material and processes into full consciousness so that the patient can gain more control over his or her life.

Classical psychoanalysis has become the least commonly practiced form of psychodynamic therapy because of its demands on the patient's time, as well as on his or her emotional and financial resources. It is, however, the oldest form of psychodynamic treatment. The theories that underlie psychoanalysis were worked out by Sigmund Freud (1856–1939), a Viennese physician, during the early years of the twentieth century. Freud's discoveries were made in the context of his research into hypnosis. The goal of psychoanalysis is the uncovering and resolution of the patient's internal conflicts. The treatment focuses on the formation of an intense relationship between the therapist and patient, which is analyzed and discussed in order to deepen the patient's insight into his or her problems.

Psychoanalytic psychotherapy is a modified form of psychoanalysis that is much more widely practiced. It is based on the same theoretical principles as psychoanalysis, but is less intense and less concerned with major changes in the patient's character structure. The focus in treatment is usually the patient's current life situation and the way problems relate to early conflicts and feelings, rather than an exploration of the unconscious aspects of the relationship that has been formed with the therapist.

Not all patients benefit from psychoanalytic treatment. Potential patients should meet the following prerequisites:

• The capacity to relate well enough to form an effective working relationship with the analyst. This relationship is called a therapeutic alliance.
• At least average intelligence and a basic understanding of psychological theory.
• The ability to tolerate frustration, sadness, and other painful emotions.
• The capacity to distinguish between reality and fantasy.

People considered best suited to psychoanalytic treatment include those with depression, character disorders, neurotic conflicts, and chronic relationship problems. When the patient's conflicts are long-standing and deeply entrenched in his or her personality, psychoanalysis may be preferable to psychoanalytic psychotherapy, because of its greater depth.

Precautions

Psychoanalysis is not suitable for patients suffering from severe depression or psychotic disorders such as schizophrenia. It is also not appropriate for people with addictions or substance dependency, disorders of aggression or impulse control, or acute crises; some of these people may benefit from psychoanalysis after the crisis has been resolved.

Description

In both psychoanalysis and psychoanalytic psychotherapy, the therapist does not tell the patient how to solve problems or offer moral judgments. The focus of treatment is exploration of the patient's mind and habitual thought patterns. Such therapy is termed "non-directed." It is also "insight-oriented," meaning that the goal of treatment is increased understanding of the sources of one's inner conflicts and emotional problems. The basic techniques of psychoanalytical treatment include:

Therapist neutrality

Neutrality means that the analyst does not take sides in the patient's conflicts, express feelings about the patient, or talk about his or her own life. Therapist neutrality is intended to help the patient stay focused on issues rather than be concerned with the therapist's reactions. In psychoanalysis, the patient lies on a couch facing away from the therapist. In psychodynamic psychotherapy, however, the patient and therapist usually sit in comfortable chairs facing each other.

Free association

Free association means that the patient talks about whatever comes into mind without censoring or editing the flow of ideas or memories. Free association allows the patient to return to earlier or more childlike emotional states ("regress"). Regression is sometimes necessary in the formation of the therapeutic alliance. It also helps the analyst to understand the recurrent patterns of conflict in the patient's life.

Therapeutic alliance and transference

Transference is the name that psychoanalysts use for the patient's repetition of childlike ways of relating that were learned in early life. If the therapeutic alliance has been well established, the patient will begin to transfer thoughts and feelings connected with siblings, parents, or other influential figures to the therapist. Discussing the transference helps the patient gain insight into the ways in which he or she misreads or misperceives other people in present life.

Interpretation

In psychoanalytic treatment, the analyst is silent as much as possible, in order to encourage the patient's free association. However, the analyst offers judiciously timed interpretations, in the form of verbal comments about the material that emerges in the sessions. The therapist uses interpretations in order to uncover the patient's resistance to treatment, to discuss the patient's transference feelings, or to confront the patient with inconsistencies. Interpretations may be either focused on present issues ("dynamic") or intended to draw connections between the patient's past and the present ("genetic"). The patient is also often encouraged to describe dreams and fantasies as sources of material for interpretation.

Working through

"Working through" occupies most of the work in psychoanalytic treatment after the transference has been formed and the patient has begun to acquire insights into his or her problems. Working through is a process in which the new awareness is repeatedly tested and "tried on for size" in other areas of the patient's life. It allows the patient to understand the influence of the past on his or her present situation, to accept it emotionally as well as intellectually, and to use the new understanding to make changes in present life. Working through thus helps the patient to gain some measure of control over inner conflicts and to resolve them or minimize their power.

Although psychoanalytic treatment is primarily verbal, medications are sometimes used to stabilize patients with severe anxiety, depression, or other mood disorders during the analysis.

The cost of either psychoanalysis or psychoanalytic psychotherapy is prohibitive for most patients without insurance coverage. A full course of psychoanalysis usually requires three to five weekly sessions with a psychoanalyst over a period of three to five years. A course of psychoanalytic psychotherapy involves one to three meetings per week with the therapist for two to five years. Each session or meeting typically costs between $80 and $200, depending on the locale and the experience of the therapist. The increasing reluctance of most HMOs and other managed care organizations to pay for long-term psychotherapy is one reason that these forms of treatment are losing ground to short-term methods of treatment and the use of medications to control the patient's emotions. It is also not clear that long-term psy-choanalytically oriented approaches are more beneficial than briefer therapy methods for many patients.

Preparation

Some patients may need evaluation for possible medical problems before entering psychoanalysis because numerous diseases—including virus infections and certain vitamin deficiencies—have emotional side effects or symptoms. The therapist will also want to know whether the patient is taking any prescription medications that may affect the patient's feelings or ability to concentrate. In addition, it is important to make sure that the patient is not abusing drugs or alcohol.

Risks

The primary risk to the patient is related to the emotional pain resulting from new insights and changes in long-standing behavior patterns. In some patients, psychoanalysis produces so much anxiety that they cannot continue with this treatment method. In other cases, the therapist's lack of skill may prevent the formation of a solid therapeutic alliance.

Normal results

Psychoanalysis and psychoanalytic psychotherapy both have the goal of basic changes in the patient's personality structure and level of functioning, although psychoanalysis typically aims at more extensive and more profound change. In general, this approach to treatment is considered successful if the patient has shown:

• reduction in intensity or number of symptoms
• some resolution of basic emotional conflicts
• increased independence and self-esteem
• improved functioning and adaptation to life

Attempts to compare the effectiveness of psychoanalytical treatment to other modes of therapy are difficult to evaluate. Some aspects of Freudian theory have been questioned since the 1970s on the grounds of their limited applicability to women and to people from non-Western cultures. There is, however, general agreement that psychoanalytic approaches work well for certain types of patients. In particular, these approaches are recommended for patients with neurotic conflicts.