Psychoanalytic psychotherapy

What is Psychoanalytic psychotherapy?

Psychoanalytic Psychotherapy is psychotherapy based on the principles of psychoanalysis. Psychoanalysis was pioneered by Sigmund Freud and others in Europe in the late nineteenth and early twentieth centuries. Since then it has undergone diversification throughout much of the world and into various strands of emphasis, but most strands retain a core of agreement. This discipline is a theory of human development, a theory of personality, and a theory of how to conduct therapy. There are psychoanalytic couple, family, child, and group approaches to psychotherapy. In addition the ideas have been extended to reflect on social life and society, and art and literature, but I will focus here on individual psychoanalytic psychotherapy.

Finding the underlying causes

“Psychoanalytic psychotherapy is based on psychoanalytic practice and theory. It endeavours to reach the underlying, often unconscious, causes of distress. Together with the therapist, the patient can explore free associations, memories, phantasies, feelings and dreams, relating to both past and present. In the reliable setting of the therapy (which allows for regression) and in the exploration of the interactions with the therapist, especially within the transference and countertransference, the patient may achieve a new and better resolution of long-standing conflicts”.

This definition is from the UK Council for Psychotherapy (from their Psychoanalytic and Psychodynamic Psychotherapy Section). For me it captures what is distinctive about psychoanalytic psychotherapy, the focus on underlying causes of distress, the detailed attention to all of the world of the patient and their experience, and the structured focus on the therapeutic relationship and in particular the transference/countertransference matrix.

There is much to say on many of the terms used above, but for now I want to focus on the questions of whether psychoanalytic psychotherapy works, and issues to consider if you are interested in pursuing this opportunity.

Does it work?

How well any psychotherapy ‘works’ needs to be seen in the context that the technologies used to investigate psychotherapy have often been those designed to evaluate one drug against another or against a placebo, with no regard for the two people involved and more importantly the relationship between them.

Nonetheless, in a seminal paper on the efficacy of psychodynamic psychotherapy, the American psychologist Jonathan Shedler highlights the efficacy of psychotherapy in general as well as the contribution of the elements of the psychodynamic approach to any successful psychotherapy. (His descriptor ‘psychodynamic’ is broader than psychoanalytic, but, from his description of the elements, firmly contains psychoanalytic psychotherapy). He then reviews studies that have demonstrated high effect sizes for psychoanalytic psychotherapies, higher than those for cognitive behaviour therapy and significantly higher than those for anti-depressant drug treatment.

In particular and uniquely, the effect sizes for psychodynamic psychotherapies showed an almost universal pattern of significant increase over time. Other approaches and medication tend to show a decrease over time. This is in line with what one would expect from psychoanalytic theory, that something significant and fundamental has changed, and that that process of change can continue following a successful therapy.

The couch & session frequency

Two key issues that are important in considering types of psychoanalytic psychotherapy are frequency of sessions, and the use of the analytic couch. Typically a full psychoanalysis will involve four to five sessions per week, and for much of the process the analysand will lie on a couch, often with the analyst out of their view. The use of the couch can make regression more possible, and can allow for a freedom of associations not restricted by face-to-face contact with the analyst.

At the same time, for the analyst, the use of the couch gives a freedom from the need for face-to-face contact. It can also enable the process of reverie in the analyst, allowing their mind to wander (and wonder) in an intuitive way in response to the analysand. One way of thinking about the couch can be to reflect on how it can be easier to have a deeper conversation with a companion when sitting side-by-side on a car journey, or walking side-by-side.

Turning to psychoanalyic psychotherapy rather than psychoanalysis, this more typically involves between one and three sessions each week, and may or may not involve use of the couch. The decisions about frequency and use of the couch are complex.

First, there is the issue of the training of the therapist. In general, it is important that they themselves have undertaken therapy at the frequency at which they will be working.
Second, there is the question of the patient’s resources, both of time and money.
Thirdly, for some patients, the regression and exploration involved in frequent sessions on the couch may not be what they need, and they may need more focus on their experience day to day outside of therapy. In the light of growing understanding of processes of attachment, some therapists consider that face-to-face contact is essential as this is so much part of the formation of attachments in infancy.
However, fourthly, through a mix of training, therapy and clinical experience, therapists can acquire a capacity to offer psychoanalytic psychotherapy which does not depend on a full psychoanalytic training.

Often these decisions, about frequency of sessions and use of the couch, can be clouded by professional politics. In conclusion, my own view is that the relationship between frequency of sessions and therapeutic impact is not linear, with increasingly greater impact of more frequent sessions, and that use of the couch as appropriate can enable deeper exploration than face-to-face work.

Other considerations

Regarding issues to consider if wondering about this opportunity, motivation, resources and context are all important.

Opportunity is a deliberate choice of word, because it highlights that this is a chance to be actively seized rather than a treatment to be passively endured.
Regarding motivation, this is hard work. There are effective shorter-term psychoanalytic psychotherapies, but these are themselves demanding of the patient. If you can sustain yourself through the difficult patches, psychoanalytic psychotherapies pay dividends.
Regarding resources, such a venture has costs, although these are at least broadly predictable. Also, such costs can genuinely be seen as an investment in future wellbeing.
Finally, context is significant. Unless you contract for a Brief therapy, a substantial psychoanalytic psychotherapy will need to last for a couple of years at least. Early psychoanalysts warned against taking any significant life decision during analysis. Whilst our social context is profoundly different in some ways so that this may not be realistic, the importance of a willingness to consider such decisions in therapy is paramount in order to avoid unconscious and potentially destructive acting-out.