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
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.
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.
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:
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 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
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" 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.
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.
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.
The primary risk to the patient is related to the emotional pain resulting from new insights and changes in
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.
Glick, Robert Alan, and Henry I. Spitz. "Common Approaches to Psychotherapy." In The Columbia University College of Physicians and Surgeons Complete Home Guide to Mental Health, ed. Frederic I. Kass, et al. New York: Henry Holt and Co., 1992.
Meissner, W. W. "The Psychotherapies: Individual, Family, and Group." In The New Harvard Guide to Psychiatry,ed. Armand M. Nicholi Jr. Cambridge, MA: The Belknap Press of Harvard University Press, 1988.
"Theories of Personality." In The New Harvard Guide to Psychiatry, ed. Armand M. Nicholi Jr. Cambridge, MA: The Belknap Press of Harvard University Press, 1988.
Rebecca J. Frey
Free association—A technique used in psychoanalysis in which the patient allows thoughts and feelings to emerge without trying to organize or censor them.
Interpretation—A verbal comment made by the analyst in response to the patient's free association. It is intended to help the patient gain new insights.
Neurosis—A mental and emotional disorder that affects only part of the personality and is accompanied by a significantly less distorted perception of reality than in psychosis.
Psychodynamic—An approach to psychotherapy based on the interplay of conscious and unconscious factors in the patient's mind. Psychoanalysis is one type of psychodynamic therapy.
Regression—The process in which the patient reverts to earlier or less mature feelings and behaviors.
Therapeutic alliance—The working relationship between a therapist and a patient that is necessary to the success of therapy.
Transference—The process that develops during psychoanalytic work during which the patient redirects feelings about early life figures toward the analyst.
Working through—The repeated testing of insights, which takes up most of the work in psychoanalysis after the therapeutic alliance has been formed.