Psychoanalysis

Psychoanalysis is a form of psychotherapy used by qualified psychotherapiststo 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 betweenconscious and unconscious mental processes, and should not be used as a synonym for psychotherapy in general. Psychoanalysis is done one-on-one with thepatient and the analyst; it is not appropriate for group work.

Psychoanalysis is the most intensive form of an approach to treatment calledpsychodynamic 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 mentalmaterial and processes into full consciousness so that the patient can gainmore 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 onhis or her emotional and financial resources. It is, however, the oldest form of psychodynamic treatment. The theories that underlie psychoanalysis wereworked out by Sigmund Freud (1856-1939), a Viennese physician, duringthe early years of this century. Freud's discoveries were made in the contextof his research into hypnosis. The goal of psychoanalysis is the uncoveringand resolution of the patient's internal conflicts. The treatment focuses onthe formation of an intense relationship between the therapist and patient, which is analyzed and discussed in order to deepen the patient's insight intohis 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 andfeelings, 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 intelligenceand 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 withdepression, character disorders, neurotic conflicts, and chronic relationshipproblems. 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 depressionor psychotic disorders such as schizophrenia. It is also not appropriate forpeople 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 focusof 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 ofone'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, thepatient 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 mindwithout censoring or editing the flow of ideas or memories. Free associationallows 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 patternsof conflict in the patient's life.

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

In psychoanalytic treatment, the analyst is silent as much as possible, in order to encourage the patient's free association. However, the analyst offersjudiciously 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 afterthe 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 innerconflicts 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 mooddisorders 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 overa 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 onthe locale and the experience of the therapist. The increasing reluctance ofmost 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'semotions. It is also not clear that long-term psychoanalytically 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 prescriptionmedications 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 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.

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 andself-esteem
  • Improved functioning and adaptation to life.

Attempts to compare the effectiveness of psychoanalytical treatment to othermodes 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 ofpatients. In particular, these approaches are recommended for patients with neurotic conflicts.

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