The Elements Of Practical Psycho-Analysis: Volume 45 (International Library of Psychology)

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The evidence base for psychoanalytic therapy remains thin. There is little doubt that the absence of solid and persuasive evidence for the efficacy of psychoanalysis is the consequence of the self-imposed isolation of psychoanalysis from the empirical sciences. Few would dispute the assertion that psychoanalytic theory is in a perilous state. The psychoanalytic clinical situation might have yielded all that it can offer to advance our understanding of mind.

Yet 'importing' extra-clinical data is often fiercely resisted and those psychoanalysts who have attempted to do so have commonly been subjected to subtle and not so subtle derision. Psychoanalysts have been encouraged by the body of research that supports brief dynamic psychotherapy.

A meta-analysis of 26 such studies has yielded effect sizes comparable to other approaches It may even be slightly superior to some other therapies if long term follow-up is included in the design. One of the best designed randomized controlled trials RCTs , the Sheffield Psychotherapy Project 32 , found evidence for the effectiveness of a 16 session psychodynamic treatment based on Hobson's model 33 in the treatment of major depression.

There is evidence for the effectiveness of psychodynamic therapy as an adjunct to drug dependence programs There is ongoing work on a brief psychodynamic treatment for panic disorder There is evidence for the use of brief psychodynamic approaches in work with older people There are psychotherapy process studies which offer qualified support for the psychoanalytic case.

For example, psychoanalytic interpretations given to clients which are judged to be accurate are reported to be associated with relatively good outcome 37 , Evidence is available to support therapeutic interventions which are clear derivatives of psychoanalysis. However, most analysts would consider that the aims and methods of short-term once a week psychotherapy are not comparable to 'full analysis'. What do we know about the value of intensive and long-term psychodynamic treatment?

Here the evidence base becomes somewhat patchy. The Boston Psychotherapy Study 40 compared longterm psychoanalytic therapy two or more times a week with supportive therapy for clients with schizophrenia in a randomized controlled design. There were some treatment specific outcomes, but on the whole clients who received psychoanalytic therapy fared no better than those who received supportive treatment. In a more recent randomized controlled study 41 , individuals with a diagnosis of borderline personality disorder were assigned to a psychoanalytically oriented day-hospital treatment or treatment as usual.

The psychoanalytic arm of the treatment included therapy groups three times a week as well as individual therapy once or twice a week over an 18 month period. There were considerable gains in this group relative to the controls and these differences were not only maintained in the 18 months following discharge, but increased, even though the day hospital group received less treatment than the control group The cost-effectiveness of these treatments is surprisingly impressive, with the cost of psychoanalytic partial hospital treatment comparable to treatment as usual for these patients, and the costs of the treatment mostly recovered in terms of savings in service use within 18 months of the end of treatment 43 - Trials with similar patient groups using comparisons of outpatient psychoanalytic therapy treatments with extended baselines have yielded relatively good outcomes 47 as did comparisons with treatment as usual Several prospective follow-along studies using a pre-post design have suggested substantial improvements in patients given psychoanalytic therapies for personality disorders 49 - Uncontrolled studies, however, particularly those with relatively small sample sizes and clinical populations whose condition is known to fluctuate wildly, cannot yield data of consequence concerning what type of treatment is likely to be effective for whom.

A further controlled trial of intensive psychoanalytic treatment of children with chronically poorly controlled diabetes reported significant gains in diabetic control in the treated group which was maintained at one year follow-up Experimental single case studies carried out with the same population supported the causal relationship between interpretive work and improvement in diabetic control and physical growth The work of Heinicke also suggests that four or five times weekly sessions may generate more marked improvements in children with specific learning difficulties than a less intensive psychoanalytic intervention One of the most interesting studies to emerge recently was the Stockholm Outcome of Psychotherapy and Psychoanalysis Project The study followed persons who received national insurance funded treatment for up to three years in psychoanalysis or in psychoanalytic psychotherapy.

The groups were matched on many clinical variables. Four or five times weekly analysis had similar outcomes at termination when compared with one to two sessions per week psychotherapy. However, in measurements of symptomatic outcome using the Short Check List SCL , improvement on three year follow-up was substantially greater for individuals who received psychoanalysis than those in psychoanalytic psychotherapy. In fact, during the follow-up period, psychotherapy patients did not change, but those who had had psychoanalysis continued to improve, almost to a point where their scores were indistinguishable from those obtained from a non-clinical Swedish sample.

A large scale follow-up study of a representatively selected group of psychoanalytically and psychotherapeutically treated individuals was recently reported from the German Psychoanalytic Association's collaborative investigation A selection of patients whose treatments had taken place in a designated time period were interviewed by independent assessors and outcomes assessed by both standardized and interviewer coded instruments.

Follow-up data was favorable in relation to both anxiety and depression and savings were also demonstrated in relation to the use of hospital and outpatient medical treatment of physical symptoms replicating earlier German investigations This carefully conducted study also provided important qualitative data in relation to the experience of psychoanalytic treatment and the relatively common disjunction of psychological changes at the level of self-understanding, and interpersonal-relational and work-related domains. Another large pre-post study of psychoanalytic treatments has examined the clinical records of children who were evaluated and treated at the Anna Freud Centre, under the close supervision of Freud's daughter 58 - Children with certain disorders e.

Interestingly, children with severe emotional disorders three or more Axis I diagnoses did surprisingly well in psychoanalysis, although they did poorly in once or twice a week psychoanalytic psychotherapy. Younger children derived greatest benefit from intensive treatment. Adolescents appeared not to benefit from the increased frequency of sessions. The importance of the study is perhaps less in demonstrating that psychoanalysis is effective, although some of the effects on very severely disturbed children were quite remarkable, but more in identifying groups for whom the additional effort involved in intensive treatment appeared not to be warranted.

The Research Committee of the International Psychoanalytic Association has recently prepared a comprehensive review of North American and European outcome studies of psychoanalytic treatment The Committee concluded that existing studies failed to unequivocally demonstrate that psychoanalysis is efficacious relative to either an alternative treatment or an active placebo, and identified a range of methodological and design problems in the fifty or so studies described in the report.

Nevertheless, the report is encouraging to psychoanalysts.

A number of studies testing psychoanalysis with 'state of the art' methodology are ongoing and are likely to produce more compelling evidence over the next years. Despite the limitations of the completed studies, evidence across a significant number of pre-post investigations suggested that psychoanalysis appears to be consistently helpful to patients with milder neurotic disorders and somewhat less consistently so for other, more severe groups.

Across a range of uncontrolled or poorly controlled cohort studies, mostly carried out in Europe, longer intensive treatments tended to have better outcomes than shorter, non-intensive treatments. The impact of psychoanalysis was apparent beyond symptomatology, in measures of work functioning and reductions in health care costs.

There are limitations concerning the nature of the evidence base for all psychotherapies. These limitations are well-known and their implications go well beyond the evaluation of the current status of psychoanalysis. The outcomes literature concerns RCTs administered over relatively brief periods three to six months with short follow-ups and a failure to control for inter-current treatments over these periods.

Most evidence-based treatment reviews have been uniquely based on RCTs. RCTs in psychosocial treatments are often regarded as inadequate because of their low external validity or generalizability In brief, they are not relevant to clinical practice - a hotly debated issue in the field of psychotherapy 64 and psychiatric research There are a number of well publicized reasons: Belief in the supremacy of RCTs opens the door to treatments which, even if effective, one may not wish to entertain.

A recent report in the British Medical Journal on the effects of remote, retro-active intercessory prayer on the outcome of patients with bloodstream infection is salutary. Leonard Leibovici 67 from the Rabin Medical Centre in Israel randomized 3, adult patients whose bloodstream infection was detected in the hospital between and A list of the first names of the patients in the intervention group was given to a person who said a short prayer for the wellbeing and recovery of the group as a whole. It was argued that as God is unlikely to be limited by linear time, an intervention carried out years after the patients' infection and hospitalization was as likely to be effective as one carried out during the infection.

Staggeringly, there were significant results on two of the three outcome measures. Length of hospital stay and duration of fever were both shorter in the intervention group. Mortality was also lower in the intervention group but the difference was not statistically significant. As two other independent studies also support intercessory prayer 68 , 69 by the American Psychological Association's criteria for empirically based treatments, this intervention should be accepted except for the heterogeneity of the medical conditions for which the treatment was used.

This finding highlights the risk associated with an atheoretical stance to evidence based practice that reifies and idealises a research design. RCTs unquestionably have the potential to yield clinically relevant data in the absence of an adequate understanding of the underlying process. When James Lind in determined that lemons and limes cured scurvy, he knew nothing about ascorbic acid, nor did he understand the concept of a nutrient. Yet Leibovici's study demonstrates the absurdity which can be created by bringing the world of rigorous measurement into a domain that is totally unsuited to it.

Most importantly from the standpoint of psychoanalysis, the current categorization in evidence-based psychotherapies conflates two radically different groups of treatments: It is important to make this distinction, since the reason that a treatment has not been subjected to empirical scrutiny may have little to do with its likely effectiveness. It may have far more to do with the intellectual culture within which researchers operate, the availability of treatment manuals, and peer perceptions of the value of the treatment which can be critical for both funding and publication.

The British psychodynamically oriented psychiatrist Jeremy Holmes 70 has eloquently argued in the British Medical Journal that the absence of evidence for psychoanalytic treatment should not be confused with evidence of ineffectiveness. In particular, his concern was that cognitive therapy would be adopted by default because of its research and marketing strategy rather than its intrinsic superiority.

Whilst the present author is entirely in sympathy with Holmes' perspective, even if his work with Roth 74 was one of the targets of his criticism, it is only fair to expose the shortcomings of his communication. Tarrier 75 , in a commentary on Holmes' piece, writes with passion: It has been around for years or so. The argument, therefore, becomes a little less compelling when psychotherapy's late arrival at the table of science has been triggered by a threat to pull the plug on public funding because of the absence of evidence".

Sensky and Scott 76 were similarly outraged both by Holmes' selective review of evidence and his allegations that some cognitive therapists are starting to question aspects of their discipline. The message from the CBT camp is this: Of course, psychodynamic clinicians are at a disadvantage and not simply because they are late starters after all, many new treatments find a place at the table of evidence based practice.

There are profound incompatibilities between psychoanalysis and modern natural science. Whittle 77 has drawn attention to the fundamental incompatibility of an approach that aims to fill in gaps in self-narrative with cognitive psychology's commitment to minimal elaboration of observations, a kind of Wittgensteinian cognitive asceticism. In the former context, success is measured as eloquence or meaningfulness which is not reducible to either symptom or suffering.

Moreover, psychoanalytic explanations invoke personal history, but behaviour genetics has brought environmental accounts into disrepute. To make matters worse, within psychoanalysis there has been a tradition of regarding the uninitiated with contempt, scaring off most open-minded researchers. Psychoanalysts are not yet fully committed to systematically collecting data with the potential to challenge and contradict as well as to confirm cherished ideas.

The danger that must be avoided at all costs is that research is embraced selectively only when it confirms previously held views. This may be a worse outcome than the wholesale rejection of the entire enterprise of seeking evidence, since it immunizes against being affected by findings at the same time as creating an illusion of participation in the virtuous cycle of exploring, testing, modifying and re-exploring ideas. But the absence of psychoanalytic research raises a related problem that particularly concerns me.

This becomes a pernicious self-fulfilling prophecy, as investigators who favour less focused more long-term treatment approaches are gradually excluded from the possibility of receiving funding and, if their treatments are subjected to systematic inquiry at all, these studies are performed by those with least interest in such treatments. Our aim should be to assist the movement of psychoanalysis toward science. In order to ensure a future for psychoanalysis and psychoanalytic therapies within psychiatry, psychoanalytic practitioners must change their attitude in the direction of a more systematic outlook.

This attitude shift would be characterized by several components: New evidence may assist psychoanalysts in resolving theoretical differences, a feat which the current database of predominantly anecdotal clinical accounts have not been capable of achieving. Instead of fearing that fields adjacent to psychoanalysis might destroy the unique insights offered by clinical work, we need to embrace the rapidly evolving 'knowledge chain' focused at different levels of the study of brain-behavior relationship, which, as Kandel 7 , 79 points out, may be the only route to the preservation of the hard won insights of psychoanalysis.

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Hate in the Counter-Transference. The Theory of the Parent-Infant Relationship. Notes on Some Schizoid Mechanisms. Non-Interpretive Mechanisms in Psychoanalytic Therapy: Beyond Doer and Done to: An Intersubjective View of Thirdness. The Psycho-Analytic Study of Thinking. Working with Intersubjective Clinical Facts. The Analytic Situation as a Dynamic Field.

Psychoanalysis today

The Language of Psycho-Analysis. The Language of Winnicott: A Dictionary of Winnicott's Use of Words. Clinical Lectures on Klein and Bion. Therapeutic Aspects of Regression. Experiences in Groups And Other Papers. Separation, Anxiety and Anger. Loss, Sadness and Depression. The Oedipus Complex Today: Selected Problems of Adolescence: With Special Emphasis on Group Formation. Child and Adolescent Analysis: The Psychology and Treatment of Addictive Behavior. Psychoanalytic Studies of the Personality. First Contributions to Psycho-Analysis. Psychoanalysis and the War Neuroses. Letters of Sigmund Freud An Introduction to the British School.

The Meaning of Illness. Thinking about lnfants and Young Children. Emily Dickinson in Time: Papers on Child Development and Psychoanalytic Training. Ego Psychology and the Problem of Adaptation. The Mind's Extensive View: Years of Maturity The Last Phase The Young Freud Psychic Equilibrium and Psychic Change. Clinical Studies in Neuro-Psychoanalysis: Introduction to a Depth Neuropsychology. The Freud-Klein Controversies The Psycho-Analysis of Children. Narrative of a Child Analysis. Envy and Gratitude and Other Works Thinking, Feeling, and Being. Sexual States of Mind.

Studies in Extended Metapsychology: Clinical Applications of Bion's Ideas. An Investigation of Claustrophobic Phenomena. The Apprehension of Beauty: The Hands of the Living God: An Account of a Psycho-analytic Treatment. The suppressed madness of sane men: Forty-four Years of Exploring Psychoanalysis. The Newborn in the lntensive Care Unit: A Neuropsychoanalytical Prevention Method. The Story of lnfant Development. Selected Contributions to Psycho-Analysis. The Reconstruction of Trauma: The Interpretation of Dreams in Clinical Work.

A Matter of lnterest: Clinical Notes of a Psychoanalyst in General Practice. The Emotional Experience in General Practice. The Revolution in Psychoanalysis. Essays in Honour of Arnold Cooper. Narrative Truth and Historical Truth. The Interpersonal World of the Infant. Psychoanalytic Practice, Volume 1: Psychoanalytic Practice, Volume 2: Life Inside the Controversy. Forty-Two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy. A Strange Way of Killing: The Poetic Structure of Wuthering Heights.

The Vale of Soulmaking: The Poetic Spirit of Psychoanalysis. The Chamber of Maiden Thought: Literary Origjns of the Psychoanalytic Model of the Mind. The Maturational Processes and the Facilitating Environment. Therapeutic Consultations in Child Psychiatry. Through Paediatrics to Psycho-Analysis. To find an author, select the first letter of the last name: At least times in the past 5 years by other PEP-Web documents at least the selected number of times.

At least times in the last week month six months year PEP-Web at least the selected number of times. Kimpton, London, , Pp. The Psychology of Medicine: Psycho-Analysis and the War Neuroses: Moffat Yard and Co. An Introduction to the Study of Psycho-Analysis: An Introduction to Psychology: Mind and its Disorders: Ernst Bircher, Bern and Leipzig, Edition Atar, Paris and Geneva, Price 15 Swiss Francs.

Im Lichte Freier Forschung: Ernst Reinhardt, Munich, Cambridge University Press, Lacan's concepts concern the " mirror stage ", the "Real" , the "Imaginary" , and the "Symbolic" , and the claim that "the unconscious is structured as a language". Though a major influence on psychoanalysis in France and parts of Latin America, Lacan and his ideas have taken longer to be translated into English and he has thus had a lesser impact on psychoanalysis and psychotherapy in the English-speaking world.

In the United Kingdom and the United States, his ideas are most widely used to analyze texts in literary theory. Interpersonal psychoanalysis accents the nuances of interpersonal interactions, particularly how individuals protect themselves from anxiety by establishing collusive interactions with others, and the relevance of actual experiences with other persons developmentally e. This is contrasted with the primacy of intrapsychic forces, as in classical psychoanalysis.

Some psychoanalysts have been labeled culturalist , because of the prominence they attributed culture in the genesis of behavior. Feminist theories of psychoanalysis emerged towards the second half of the 20th century, in an effort to articulate the feminine, the maternal and sexual difference and development from the point of view of female subjects.

For Freud, male is subject and female is object. For Freud , Winnicott and the object relations theories, the mother is structured as the object of the infant's rejection Freud and destruction Winnicott. For Lacan , the "woman" can either accept the phallic symbolic as an object or incarnate a lack in the symbolic dimension that informs the structure of the human subject. Feminist psychoanalysis is mainly post-Freudian and post-Lacanian with theorists like Toril Moi , Joan Copjec , Juliet Mitchell , [55] Teresa Brennan [56] and Griselda Pollock , [57] following French feminist psychoanalysis, [58] the gaze and sexual difference in, of and from the feminine.

The "adaptive paradigm of psychotherapy" develops out of the work of Robert Langs. The adaptive paradigm interprets psychic conflict primarily in terms of conscious and unconscious adaptation to reality. Relational psychoanalysis combines interpersonal psychoanalysis with object-relations theory and with inter-subjective theory as critical for mental health. It was introduced by Stephen Mitchell. Fonagy and Target, in London, have propounded their view of the necessity of helping certain detached, isolated patients, develop the capacity for "mentalization" associated with thinking about relationships and themselves.

Arietta Slade, Susan Coates , and Daniel Schechter in New York have additionally contributed to the application of relational psychoanalysis to treatment of the adult patient-as-parent, the clinical study of mentalization in parent-infant relationships, and the intergenerational transmission of attachment and trauma. The term interpersonal-relational psychoanalysis is often used as a professional identification. Psychoanalysts under this broader umbrella debate about what precisely are the differences between the two schools, without any current clear consensus.

The term " intersubjectivity " was introduced in psychoanalysis by George E. Atwood and Robert Stolorow Intersubjective approaches emphasize how both personality development and the therapeutic process are influenced by the interrelationship between the patient's subjective perspective and that of others. The authors of the interpersonal-relational and intersubjective approaches: Levenson, Jay Greenberg , Edward R. Ritvo, Beatrice Beebe, Frank M. Lachmann, Herbert Rosenfeld and Daniel Stern. Interventions based on this approach are primarily intended to provide an emotional-maturational communication to the patient, rather than to promote intellectual insight.

These interventions, beyond insight directed aims, are used to resolve resistances that are presented in the clinical setting. This school of psychoanalysis has fostered training opportunities for students in the United States and from countries worldwide. Its journal Modern Psychoanalysis has been published since The various psychoses involve deficits in the autonomous ego functions see above of integration organization of thought, in abstraction ability, in relationship to reality and in reality testing.

In depressions with psychotic features, the self-preservation function may also be damaged sometimes by overwhelming depressive affect. Because of the integrative deficits often causing what general psychiatrists call "loose associations", "blocking", " flight of ideas ", "verbigeration", and "thought withdrawal" , the development of self and object representations is also impaired.

In patients whose autonomous ego functions are more intact, but who still show problems with object relations, the diagnosis often falls into the category known as "borderline". Borderline patients also show deficits, often in controlling impulses, affects, or fantasies — but their ability to test reality remains more or less intact. Adults who do not experience guilt and shame, and who indulge in criminal behavior, are usually diagnosed as psychopaths, or, using DSM-IV-TR , antisocial personality disorder.

Panic, phobias, conversions, obsessions, compulsions and depressions analysts call these " neurotic symptoms " are not usually caused by deficits in functions. Instead, they are caused by intrapsychic conflicts. The conflicts are generally among sexual and hostile-aggressive wishes, guilt and shame, and reality factors. The conflicts may be conscious or unconscious, but create anxiety, depressive affect, and anger. Finally, the various elements are managed by defensive operations — essentially shut-off brain mechanisms that make people unaware of that element of conflict.

Neurotic symptoms may occur with or without deficits in ego functions, object relations, and ego strengths. Therefore, it is not uncommon to encounter obsessive-compulsive schizophrenics, panic patients who also suffer with borderline personality disorder , etc. This section above is partial to ego psychoanalytic theory "autonomous ego functions".

As the "autonomous ego functions" theory is only a theory, it may yet be proven incorrect. Freudian theories hold that adult problems can be traced to unresolved conflicts from certain phases of childhood and adolescence , caused by fantasy, stemming from their own drives. Freud, based on the data gathered from his patients early in his career, suspected that neurotic disturbances occurred when children were sexually abused in childhood the so-called seduction theory.

Later, Freud came to believe that, although child abuse occurs, neurotic symptoms were not associated with this. He believed that neurotic people often had unconscious conflicts that involved incestuous fantasies deriving from different stages of development. He found the stage from about three to six years of age preschool years, today called the "first genital stage" to be filled with fantasies of having romantic relationships with both parents. Arguments were quickly generated in early 20th-century Vienna about whether adult seduction of children, i.

There still is no complete agreement, although nowadays professionals recognize the negative effects of child sexual abuse on mental health. Many psychoanalysts who work with children have studied the actual effects of child abuse, which include ego and object relations deficits and severe neurotic conflicts. Much research has been done on these types of trauma in childhood, and the adult sequelae of those. In studying the childhood factors that start neurotic symptom development, Freud found a constellation of factors that, for literary reasons, he termed the Oedipus complex based on the play by Sophocles , Oedipus Rex , where the protagonist unwittingly kills his father Laius and marries his mother Jocasta.

The validity of the Oedipus complex is now widely disputed and rejected.

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Sandler in "On the Concept Superego" and modified by Charles Brenner in The Mind in Conflict — refers to the powerful attachments that children make to their parents in the preschool years. These attachments involve fantasies of sexual relationships with either or both parent, and, therefore, competitive fantasies toward either or both parents. Humberto Nagera has been particularly helpful in clarifying many of the complexities of the child through these years. Both seem to occur in development of most children. Eventually, the developing child's concessions to reality that they will neither marry one parent nor eliminate the other lead to identifications with parental values.

These identifications generally create a new set of mental operations regarding values and guilt, subsumed under the term "superego". Besides superego development, children "resolve" their preschool oedipal conflicts through channeling wishes into something their parents approve of "sublimation" and the development, during the school-age years "latency" of age-appropriate obsessive-compulsive defensive maneuvers rules, repetitive games. Using the various analytic and psychological techniques to assess mental problems, some believe that there are particular constellations of problems that are especially suited for analytic treatment see below whereas other problems might respond better to medicines and other interpersonal interventions.

To be treated with psychoanalysis, whatever the presenting problem, the person requesting help must demonstrate a desire to start an analysis. The person wishing to start an analysis must have some capacity for speech and communication.

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As well, they need to be able to have or develop trust and insight within the psychoanalytic session. Potential patients must undergo a preliminary stage of treatment to assess their amenability to psychoanalysis at that time, and also to enable the analyst to form a working psychological model, which the analyst will use to direct the treatment. Psychoanalysts mainly work with neurosis and hysteria in particular; however, adapted forms of psychoanalysis are used in working with schizophrenia and other forms of psychosis or mental disorder.

Finally, if a prospective patient is severely suicidal a longer preliminary stage may be employed, sometimes with sessions which have a twenty-minute break in the middle.

Psychoanalysis

There are numerous modifications in technique under the heading of psychoanalysis due to the individualistic nature of personality in both analyst and patient. The most common problems treatable with psychoanalysis include: The fact that many of such patients also demonstrate deficits above makes diagnosis and treatment selection difficult. Analytical organizations such as the IPA, APsaA and the European Federation for Psychoanalytic Psychotherapy have established procedures and models for the indication and practice of psychoanalytical therapy for trainees in analysis.

The match between the analyst and the patient can be viewed as another contributing factor for the indication and contraindication for psychoanalytic treatment. The analyst decides whether the patient is suitable for psychoanalysis. This decision made by the analyst, besides made on the usual indications and pathology, is also based to a certain degree by the "fit" between analyst and patient. A person's suitability for analysis at any particular time is based on their desire to know something about where their illness has come from.

Someone who is not suitable for analysis expresses no desire to know more about the root causes of their illness. An evaluation may include one or more other analysts' independent opinions and will include discussion of the patient's financial situation and insurances. The basic method of psychoanalysis is interpretation of the patient's unconscious conflicts that are interfering with current-day functioning — conflicts that are causing painful symptoms such as phobias, anxiety, depression, and compulsions.

Strachey stressed that figuring out ways the patient distorted perceptions about the analyst led to understanding what may have been forgotten also see Freud's paper "Repeating, Remembering, and Working Through". In particular, unconscious hostile feelings toward the analyst could be found in symbolic, negative reactions to what Robert Langs later called the "frame" of the therapy [71] — the setup that included times of the sessions, payment of fees, and necessity of talking.

In patients who made mistakes, forgot, or showed other peculiarities regarding time, fees, and talking, the analyst can usually find various unconscious "resistances" to the flow of thoughts sometimes called free association. When the patient reclines on a couch with the analyst out of view, the patient tends to remember more experiences, more resistance and transference, and is able to reorganize thoughts after the development of insight — through the interpretive work of the analyst.

Although fantasy life can be understood through the examination of dreams , masturbation fantasies cf. The analyst is interested in how the patient reacts to and avoids such fantasies cf. There is what is known among psychoanalysts as "classical technique", although Freud throughout his writings deviated from this considerably, depending on the problems of any given patient. Classical technique was summarized by Allan Compton, MD, as comprising instructions telling the patient to try to say what's on their mind, including interferences ; exploration asking questions ; and clarification rephrasing and summarizing what the patient has been describing.

As well, the analyst can also use confrontation to bringing an aspect of functioning, usually a defense, to the patient's attention. The analyst then uses a variety of interpretation methods, such as dynamic interpretation explaining how being too nice guards against guilt, e. Analysts can also use reconstruction to estimate what may have happened in the past that created some current issue. These techniques are primarily based on conflict theory see above.

As object relations theory evolved, supplemented by the work of John Bowlby and Mary Ainsworth , techniques with patients who had more severe problems with basic trust Erikson , and a history of maternal deprivation see the works of Augusta Alpert led to new techniques with adults.

Psychoanalysis today

These have sometimes been called interpersonal, intersubjective cf. Stolorow , relational, or corrective object relations techniques. These techniques include expressing an empathic attunement to the patient or warmth; exposing a bit of the analyst's personal life or attitudes to the patient; allowing the patient autonomy in the form of disagreement with the analyst cf.

Paul, Letters to Simon ; and explaining the motivations of others which the patient misperceives. Ego psychological concepts of deficit in functioning led to refinements in supportive therapy. These techniques are particularly applicable to psychotic and near-psychotic cf. These supportive therapy techniques include discussions of reality; encouragement to stay alive including hospitalization ; psychotropic medicines to relieve overwhelming depressive affect or overwhelming fantasies hallucinations and delusions ; and advice about the meanings of things to counter abstraction failures.

The notion of the "silent analyst" has been criticized. Actually, the analyst listens using Arlow's approach as set out in "The Genesis of Interpretation", using active intervention to interpret resistances, defenses creating pathology, and fantasies. Silence is not a technique of psychoanalysis also see the studies and opinion papers of Owen Renik, MD. It refers to the analyst's position of not taking sides in the internal struggles of the patient.

For example, if a patient feels guilty, the analyst might explore what the patient has been doing or thinking that causes the guilt, but not reassure the patient not to feel guilty. The analyst might also explore the identifications with parents and others that led to the guilt. Interpersonal—relational psychoanalysts emphasize the notion that it is impossible to be neutral. Sullivan introduced the term "participant-observer" to indicate the analyst inevitably interacts with the analysand, and suggested the detailed inquiry as an alternative to interpretation.

The detailed inquiry involves noting where the analysand is leaving out important elements of an account and noting when the story is obfuscated, and asking careful questions to open up the dialogue. Although single-client sessions remain the norm, psychoanalytic theory has been used to develop other types of psychological treatment.

Slavson , Harry Stack Sullivan , and Wolfe. Child-centered counseling for parents was instituted early in analytic history by Freud, and was later further developed by Irwin Marcus, Edith Schulhofer, and Gilbert Kliman. Psychoanalytically based couples therapy has been promulgated and explicated by Fred Sander, MD.

Techniques and tools developed in the first decade of the 21st century have made psychoanalysis available to patients who were not treatable by earlier techniques. This meant that the analytic situation was modified so that it would be more suitable and more likely to be helpful for these patients. Eagle believes that psychoanalysis cannot be a self-contained discipline but instead must be open to influence from and integration with findings and theory from other disciplines.

Psychoanalytic constructs have been adapted for use with children with treatments such as play therapy , art therapy , and storytelling. Throughout her career, from the s through the s, Anna Freud adapted psychoanalysis for children through play. Using toys and games, children are able to demonstrate, symbolically, their fears, fantasies, and defenses; although not identical, this technique, in children, is analogous to the aim of free association in adults. Psychoanalytic play therapy allows the child and analyst to understand children's conflicts, particularly defenses such as disobedience and withdrawal, that have been guarding against various unpleasant feelings and hostile wishes.

In art therapy, the counselor may have a child draw a portrait and then tell a story about the portrait. The counselor watches for recurring themes—regardless of whether it is with art or toys. Psychoanalysis can be adapted to different cultures , as long as the therapist or counselor understands the client's culture.

For example, Tori and Blimes found that defense mechanisms were valid in a normative sample of 2, Thais. The use of certain defense mechanisms was related to cultural values. For example, Thais value calmness and collectiveness because of Buddhist beliefs , so they were low on regressive emotionality. Psychoanalysis also applies because Freud used techniques that allowed him to get the subjective perceptions of his patients. He takes an objective approach by not facing his clients during his talk therapy sessions. He met with his patients wherever they were, such as when he used free association — where clients would say whatever came to mind without self-censorship.

His treatments had little to no structure for most cultures, especially Asian cultures.

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Therefore, it is more likely that Freudian constructs will be used in structured therapy Thompson, et al. In addition, Corey postulates that it will be necessary for a therapist to help clients develop a cultural identity as well as an ego identity. The cost to the patient of psychoanalytic treatment ranges widely from place to place and between practitioners.

Low-fee analysis is often available in a psychoanalytic training clinic and graduate schools. Otherwise, the fee set by each analyst varies with the analyst's training and experience. Since, in most locations in the United States, unlike in Ontario and Germany, classical analysis which usually requires sessions three to five times per week is not covered by health insurance, many analysts may negotiate their fees with patients whom they feel they can help, but who have financial difficulties. The modifications of analysis, which include psychodynamic therapy, brief therapies, and certain types of group therapy cf.

As a result of the defense mechanisms and the lack of access to the unfathomable elements of the unconscious, psychoanalysis can be an expansive process that involves 2 to 5 sessions per week for several years. This type of therapy relies on the belief that reducing the symptoms will not actually help with the root causes or irrational drives. The analyst typically is a 'blank screen', disclosing very little about themselves in order that the client can use the space in the relationship to work on their unconscious without interference from outside. The psychoanalyst uses various methods to help the patient to become more self-aware and to develop insights into their behavior and into the meanings of symptoms.

First and foremost, the psychoanalyst attempts to develop a confidential atmosphere in which the patient can feel safe reporting his feelings, thoughts and fantasies. Analysands as people in analysis are called are asked to report whatever comes to mind without fear of reprisal. Freud called this the "fundamental rule". Analysands are asked to talk about their lives, including their early life, current life and hopes and aspirations for the future.

They are encouraged to report their fantasies, "flash thoughts" and dreams. In fact, Freud believed that dreams were, "the royal road to the unconscious"; he devoted an entire volume to the interpretation of dreams. Also, psychoanalysts encourage their patients to recline on a couch. Typically, the psychoanalyst sits, out of sight, behind the patient. The psychoanalyst's task, in collaboration with the analysand, is to help deepen the analysand's understanding of those factors, outside of his awareness, that drive his behaviors.

In the safe environment of the psychoanalytic setting, the analysand becomes attached to the analyst and pretty soon he begins to experience the same conflicts with his analyst that he experiences with key figures in his life such as his parents, his boss, his significant other, etc. It is the psychoanalyst's role to point out these conflicts and to interpret them. The transferring of these internal conflicts onto the analyst is called "transference".

Many studies have also been done on briefer "dynamic" treatments; these are more expedient to measure, and shed light on the therapeutic process to some extent. On average, classical analysis may last 5. Longer analyses are indicated for those with more serious disturbances in object relations, more symptoms, and more ingrained character pathology. Psychoanalytic training in the United States involves a personal psychoanalysis for the trainee, approximately hours of class instruction, with a standard curriculum, over a four or five-year period. Typically, this psychoanalysis must be conducted by a Supervising and Training Analyst.

Most institutes but not all within the American Psychoanalytic Association, require that Supervising and Training Analysts become certified by the American Board of Psychoanalysts. Certification entails a blind review in which the psychoanalysts work is vetted by psychoanalysts outside of their local community.

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