PSYCHOANALYTIC THERAPY?

The term psychoanalysis refers both to a body of knowledge and a particular long-term and an especially intensive type of therapy which involves meeting with a psychoanalyst 4-5 times per week for a number of years. Psychoanalytic psychotherapy and practice on the other hand refers to a therapies and interventions that are informed by psychoanalytic theory and experience but don’t take the same intensive form as psychoanalysis. Essentially any intervention that undertakes to first understand a situation by applying psychoanalytic principles and to then formulate an intervention based on that understanding is a form of psychoanalytic practice (but not necessarily psychotherapy). This can be carried out in a variety of settings including community work, couples counselling, group therapy and even work with organisations. Although each of these settings warrants its own description and while much of this article can be applied to these settings this article focuses primarily on the individual setting i.e. one therapist and one client.

What are Psychoanalytic Principles?

Psychoanalytic knowledge has developed over a period of more than one hundred years and has grown into the most comprehensive theory of the human mind that is available today. It has grappled with many scientific advances, clinical observations and divergent theoretical developments. Together this situation has led to the formation of a discipline that while vast and diverse, is underpinned by a few key features. Some of these include the recognition that much of our psychological functioning is unconscious, that who we are always reflects our adaptation to where we have come from, that our perception of reality and our relationships is influenced by our inner worlds and that our actions are compromises between conflicting possibilities.

The psychoanalytic point of view holds that all psychological symptoms and interpersonal difficulties are ultimately meaningful and represent the best possible solution that a person, group, or couple is able to achieve in managing their lives and complex and often unconscious emotional realities at a particular moment in time. The nature of psychoanalytic work is to try and provide both a therapeutic relationship and a space in which the client is able to become open and to reflect on their selves and lives with the help of the therapist. This process provides a number of therapeutic opportunities. One of these is the potential for the client to deepen their understanding of the complex and often unconscious elements that underpin their difficulties. These new ways of understanding ones difficulties can often allow the client to make valuable changes in themselves, their relationships and in their lives.

How does it Work?

Psychoanalytic psychotherapy works by creating a safe, confidential and neutral space in which is it possible to openly share ones thoughts and concerns. The therapist listens to these in a way that aims to understand the deeper significance of what is being said. This listening is guided by a number of principles including; the appreciation that all behaviours are meaningful when considered in the context of the person’s life history, that people often avoid difficult experiences and emotions and that the strategies we developed in childhood can cause difficulties when they continue into adult contexts.

The therapeutic relationship is considered especially important in psychoanalytic therapy. The way it unfolds can, like dreams, offer a glimpse into unconscious life. We all bring aspects of our past and inner realities into present relationships and psychoanalytic therapy uses this phenomenon to help identify and work through these.

Engaging in a process like this can help to deepen ones awareness of their actions and of how their inner worlds influences their lives, emotions and perceptions of self and others. This can lead to further emotional maturity which can in turn lead to improved relationships, self-esteem, confidence, creativity and greater fulfilment i.e. less symptoms like depression, anxiety, self-destructiveness, unstable emotions, feelings of isolation etc.

What happens during the sessions?

The first few sessions usually take the form of an assessment. During this time the therapist may ask questions about a person’s history and troubles, or they may simply listen to what they have to say. Adolescents and children can find it difficult to express their thoughts and feelings, and so the therapist might help the process in these instances by asking them to draw something or to describe what they see in a picture.

The purpose of these meetings is for the therapist to gain an understanding of the nature of the client’s difficulties and whether a psychoanalytic approach will be of use. Once the therapist has a sense of the difficulty, they will share their thoughts and will make a recommendation. They may recommend short or long-term individual or group psychotherapy or they might suggest something else entirely and make a referral. The assessment phase also gives the client a chance to decide on whether they are comfortable working in this way and with this therapist.

If the therapist recommends individual psychoanalytic psychotherapy and the client accepts, the next step will be to decide how often to meet and to set up regular meeting times. Meetings typically last 50min and take place at the same time and on the same day each week. Continuity is very important for this kind of work and the client will need to attend all of the sessions. Many therapists will at this point discuss how they deal with practicalities such as payment, missed sessions, holidays and confidentiality.

The actual therapy sessions might differ from the assessment sessions, and how the therapist approaches therapy will depend on their training and on the assessment findings. In short-term therapy, the therapist will usually remain quite active. They ask questions, make challenges and keep sessions focused on a specific area. In longer term settings the therapists will usually remain less active and will leave the client to do most of the talking and to set the direction. The therapist will be listening very carefully and will over time help the client to recognise patterns and the deeper significance of what has been said and how it relates to their life challenges.

Many therapists will ask the client to begin the sessions and to put all thoughts and feelings into words (even if they seem irrelevant or embarrassing). This will probably feel uncomfortable at first, but it allows things to surface which would not have otherwise. Some therapists might suggest that some clients lie on a couch with the therapist sitting on a chair out of sight behind the client. This set up may feel strange but it does make it easier for the client to look inwards and for the therapist to notice the client’s underlying worries and how their psychology colours the world around them.

Psychoanalytic therapists will almost always limit the relationship to the therapy hour and will refrain from disclosing personal information or making physical contact. This may feel unfriendly and even rejecting to some, but this stance has been shown to be most effective in the long run. It protects the professionalism of the relationship and allows important difficulties and feelings to surface.

How long does it last?

Short-term psychoanalytic therapies last between 10 and 30 sessions. This approach is suitable for addressing things that are specific and clearly definable. For example, an isolated phobia of using elevators that appeared several months ago soon after attending the funeral of a loved one. In these instances, a fixed number of sessions will usually be set out from the beginning, and the therapy is concluded once these sessions are complete.

Short-term therapies are effective, but are usually not the best choice for generalised difficulties e.g. unstable difficult emotions, trouble sustaining relationships, long-term effects of sexual abuse, feeling empty or chronic inhibition. Current research also suggests that therapies which focus on symptoms (rather than people and their personalities) are less beneficial and durable in the long run.[i]

Most psychoanalytic therapies aim for a high level of self-awareness and emotional maturity. They ambitiously work towards altering longstanding personality patterns, and so are long-term by definition i.e. more than one year. Of course more severe or longstanding difficulties do generally require longer therapies, but this is not the only factor. Other factors include the client’s level of commitment, and the aims that the client sets out to achieve.

How often should one attend?

Psychoanalytic psychotherapy involves attending regular sessions at least once per week. Although it may be costly, it is worthwhile to seriously consider meeting more than once per week since greater frequency allows for deeper work to take place. More frequent contact helps the relationship to develop, and makes it easier for both the client and the therapist to recognise and work on what unfolds. It also allows different emotional states and thoughts to surface and this increases the scope of what can be achieved.

Is Psychoanalytic Therapy effective?

The short answer to the question is Yes… but this needs to be qualified. Psychoanalytic therapies can help a person overcome significant issues, can reduce and even eliminate certain symptoms, can improve one’s relationships, sense of self, and work performance, creativity and motivation.[ii] However, psychoanalytic psychotherapy is not magic. It involves hard work, does not cure all and will not lead to a trouble free and perpetually happy life.

The success of therapy will depend on all the factors involved i.e. the fit between the client and the therapist, the client’s motivation, dedication, and openness, the therapists training, experience and skill, and external factors such as time, resources, and support. Other important factors include the client’s wish for self-understanding, a willingness to tolerate uncertainty, and the client’s readiness to consider different points of view.

What does it help with?

Research has confirmed the effectiveness of psychoanalytic psychotherapy in addressing a variety of specific diagnoses including; mood disorders (e.g. depression), anxiety disorders (e.g. panic), eating disorders, traumatic stress disorders, dissociative disorders and personality disorders.[ii]

Psychoanalytic therapists tend to be concerned with people and their personalities and not just their specific psychiatric symptoms. This makes psychoanalytic therapy a good choice for people who don’t have a particular diagnosis, but who might be troubled by more general difficulties such as recurring relationship troubles (e.g. fear of commitment), feeling unfulfilled or inhibited in life, identity difficulties, being addicted to work, or simply wanting to engage in personal growth.

How much does it cost?

Most practitioners are mindful of medical aid rates but fees can range between R300 and R700 (US$ 43-100) per session.

 

References

[i] Waldron, S., Moscovitz, S., Lundin, J., Helm, F., &Jemerin, J. (2010). Evaluating the outcomes of psychotherapies: The Personality Health Index.Submitted for publication in Psychoanalytic Psychology.

Westen, D., Gabbard, G. O., &Blagov, P. (2006). Back to the future: Personality structure as a context for psychopathology. In R. F. Krueger & J. L., Tackett (Eds.), Personality and psychopathology (pp. 335-384). New York: Guilford.

[ii] Abbass, A. A., Hancock, J. T., Henderson, J., Kisely, S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. The Cochrane Database of Systemic Reviews, 4:CD004687.

Anderson, E. M., & Lambert, M. J. (1995). Short-term dynamically oriented psychotherapy: A review and meta-analysis. Clinical Psychology Review, 15, 503-515.

deMaat, S., de Jonghe, F., Schoevers, R., Dekker, J. (2009). The effectiveness of long-term psychoanalytic therapy: A systematic review of empirical studies. Harvard Review of Psychiatry, 17, 1-23.

Leichsenring, F., &Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300, 1551-1565.

Fonagy, P. (2006). Evidence-based psychodynamic psychotherapies.In PDM Task Force (2006), Psychodynamic diagnostic manual (pp. 765-818). Silver Spring, MD: Alliance of Psychoanalytic Organizations.

Roth, A &Fonagy, P. (2005). What Works For Whom? 2nd Ed. The Guilford Press: New York.

Sandell, R., Blomberg, J., Lazar, A., Carlsson, J., Bromberg, J., & Schubert, J. (2000). Varieties of long-term outcome among patients in psychoanalysis and long-term psychotherapy: A review of findings in the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (STOPPP). International Journal of Psychoanalysis, 81, 921-942.

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy.American Psychologist.