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Psychoanalysis is the oldest form of psychological therapy. Dubbed 'the talking cure' it aims not only to alleviate the symptoms, but to address the root causes and achieve a shift in personality.

Published onJun 17, 2017

What it is about

We could start by making a distinction between Psychiatry as a medical speciality and for example the specialities of Orthopaedic Surgery or Radiology. The diagnosis and treatment in Psychiatry are not connected in quite as straightforward way. There is a group of patients who are helped by medications, however as we know from our experience in community clinics or seeing a suicidal patient at the Emergency Department - it is not always possible to work out a treatment plan where there is a specific medication that will work. But the patients remain our patients and it is important for us to find a way how to understand them in a way that would help. Help both the patient with their suffering and help the doctor to make sense of what is going on and see the way forward.

I think many of us chose Psychiatry in part to understand something about how psychic suffering and health operate. Psychoanalysis is one such way of understanding, perhaps the one where looking into the human mind through language and emotional contact has been developed the most. A lot of other talking treatments are one way or other based on psychoanalytic understanding.

We will try to show something that in our experience seemed essential to us in our encounters with psychoanalysis. We will try to convey why one might choose to make use of weekly contact with a therapist or an analyst and we will open this with a brief look into a session.

Personal Experience

It is Thursday 8:30 pm. I am still at work. I must hurry up, my session starts in thirty minutes. Am I going to meet any traffic? The same scenario every time, three times per week. Same time that lasts exactly 50 minutes. Last time I was late for 5 minutes, so it lasted forty five. Finally got there. Fortunately on time. He opened the door. We shook hands and walked into the room. I lay on to the couch. This room has been my sanctuary for the last 6 months and I consider myself a beginner. I mostly do the talking, he rarely intervenes. I have so many things to say to myself. He hardly says anything. He usually repeats some of my words, asks or rephrases me. But I remember most of his interventions. Probably I will remember them for the rest of my life. He knows when to talk. He read me as a person like a book from the first two introductory sessions. He must have a lot of patience. I think he likes me.

Now I am looking at the ceiling. Oh, that ceiling! I know every single detail of it. I also know by heart all the books that stand on that bookshelf. I cannot believe that there are times that I forget his face. Mostly during the sessions. Is that part of this technique? Normally I cannot see him, he sits behind me.

Then something comes up and I restart the talking. I have so many things on my mind. How could I have forgotten them? Well, maybe they were not that important. Or were they? Well, we will see. If I remember them or they appear in the next sessions maybe they were. Time flies and session finishes. I didn't cry this time. They say that a successful session always involves a bit of crying. My head feels heavy, but feeling in my chest is like a feather. How does he do that? I hope I learn my self better and I don't repeat the same mistakes. I am starting to believe that this is my wisest life investment.

Not always I feel different after a psychoanalysis session. But sometimes I feel a very peculiar and unmistakable sense of the world being more alive; I can smell the various faint smells - such as the new leaves, the oncoming rain or the summer breeze much better than I otherwise can. It signifies an emotional breakthrough in the session, I think to myself.

What is psychoanalysis

In order to understand psychoanalysis, we should understand the term free association. In real life, free association can be like blurting random words or thoughts that pop into your head. It is similar to the game that we used to play when we were kids. One says a word and the other responds with the first thing that pops into his mind. This applies also to psychoanalysis. The main difference between the two, is that the patient in his ceaseless talking manages to respond to his own ideas, thoughts, fears, impulses, drives and emotions - something that couldn't happen when he was fully alert and functioned in everyday life mode. He gains access to his subconscious by digging deeper and deeper into the layers of his psyche. He finds answers to his own problems. Not always they are right. His analyst is present with his interventions in order to guide him safely through this long self-discovery journey. Many believe that being a psychoanalyst is a simple task that could be easily performed by a good friend or family members. In reality this is a highly demanding job that requires a vast set of personal skills, qualities, enduring training, supervision and many years of therapist's personal analysis.

Psychoanalysis was originally developed as a clinical method for treating neurological patients with symptoms for which there was no neurological explanation. It evolved to a much broader way of helping other kinds of patients and to an understanding of the human mind, taking the existence of an unconscious part of the mind as the key premise. Its was a radical thought for it's day, but today there would hardly be a neuroscientist, or a psychologist who would not acknowledge that a lot of processing in our brain happens unconsciously - we are not consciously aware of an awful lot of what happens in our heads. Despite many an attempt to define psychoanalysis as a philosophy or general theory, psychoanalysis has remained a clinical method and in that sense it is not something that can be learned from books. But more about the learning later.

Psychoanalysis is idiographic in approaching the patient. It looks at the individual emotional meaning for the patient's experiences - mostly those which are troubling. In doing so a psychoanalyst follows their theory of how the human mind works and their experience of how this particular patient operates, particularly in the field of interpersonal relationships.

In broad terms one can say that the psychoanalyst is attempting to understand the patient and convey that understanding to the patient. This is not done in a didactic way. Rather an emotional connection is established with the patient and it serves to convey the knowledge of the self back to the patient - often in a way that the patient has not thought about. The analyst typically listens a lot and draws attention to the salient points in the patient's stream of thoughts. This can be done via interpretations -  reflections on what the patient has conveyed, based on analyst's understanding. However interpretations are only half the story and they are much easier to write about than what is often referred to as "contact" in supervision. What I mean here is the fact that an interpretation takes place on the background of a therapeutic relationship. There is trust and an emotional connection established between the patient and the analyst - and how that happens perhaps is part of the analytic frame that we talk about in the next section.

Practical aspects

Psychoanalysis can be defined by the way how it is conducted and the way how it is taught. This will be stated from the perspective of the authors of this chapter; things that we ourselves have experienced and found useful to be known before embarking on personal analysis or training in psychoanalysis or psychotherapy.

Experiencing analysis - the frame

The analytic session happens once a day and it lasts 50 minutes - usually the analyst will have at least 5 to 10 minute break between the sessions. In Lacanian tradition the session may be ended before the 50 minutes have passed - if the analyst has detected a particular insight on the part of the patient. Frequency is at least 3 times a week, but in many countries for the treatment to be called analysis it has to proceed 4 or 5 times a week. Most often the patient lies on the couch and the analyst sits on a chair behind the patient's head. In this way there is no visual contact - a deliberate component of the method as oftentimes we take clues from the other's facial expressions when talking, hence the patient's flow of thought would be less affected by the analyst who is out of the visual field. The sessions are fixed in time - if my Tuesday's session is at 19:20 it remains so. Changes in this are very rare and have to have a serious reason. The general principle is that this particular hour the analyst is available to the patient in the consultation room. Among other things it means if I cannot make to the session, I still have to pay for it. This may seem harsh at first, but this is so only if we look at it only from the patient's perspective; it is quite clear that otherwise analysis is an unsustainable endeavour [1] .

One needs to speak freely - that is to say associate freely. However in practice one finds that there are bits and pieces that one does not want to talk about. Trust in the analyst and in the process may take time to develop. Trust is needed as the key part of the analysts job is to help the patient to talk about things that are difficult. In the frame of analysis free association means a lot more than random words - it is thought process that is put in words and this thought process also involves hearing what the analyst says and thinking about it as well as becoming aware of one's emotional responses.

Learning analysis

One becomes an International Psychoanalytic Association (IPA) recognised analyst via undertaking a training administered by an IPA component society. There are three recognised training  models [2] and they all include these parts:

  1. Theoretical learning is usually done via seminars that are based on reading certain important psychoanalytic papers. Less commonly there can also be lectures but learning has to include individual reading. It may include also a year of once weekly infant observation - this component lies between theoretical and clinical learning.

  2. Personal analysis. One cannot expect to become and analyst (or a psychodynamic psychotherapist for that matter) without experiencing the process as a patient. Often it is a requirement for entering a training scheme that you have at least a year of personal analysis.   Personal analysis has to be done with a training analyst. This is the most expensive part of the training.

  3. Supervised clinical experience. That would mean at least 2 patients treated at the same frequency one is undertaking the personal analysis at. Supervision is once a week and the supervisor has to be recognised by the training institution. One usually has to pay for supervision - the cost of a supervision session is similar to what one pays for an analytic session.

In some countries IPA component societies  administer training on 3 times weekly session basis, in some the frequency can be not less 4 and 5 times weekly. It also might be possible to undertake a training on 3 times weekly basis (this is often called intensive psychotherapy training) and then, if in your practice you are seeing patients on 4 to 5 times weekly basis for several years, - you could qualify as an analyst after a one and a half year course and supervision [3]. This can be called an advanced training scheme as it is meant for therapists who are well versed in intensive work.

Evidence base

Firstly in terms of outcome data there is a large body of research in psychodynamic approaches. Secondly, as the technological era in neurosciences has recently advanced  people are better at understanding how the brain works and quite a few findings are congruent with psychoanalytic findings. For many years the effectiveness of all the psychotherapies was a matter in question, mainly by the empiricists. Many regarded psychoanalysis as a pseudoscience, due to the fact that it's effect was not easily measurable, there was little in terms of validated assessment scales, there was lack of quantitative evidence and the end result of the therapy was primarily based on testimonials.  In the early 90's, the use of assessment scales in other psychotherapies (e.g. CBT) gave the scientific base psychological therapies needed. Recent studies have shown that in mood or anxiety disorders, psychoanalysis had greater effect when compared to shorter term psychotherapies in the 5 year follow-up [4]  Psychoanalysis is not effective for obsessive-compulsive disorder, post-traumatic stress disorder, bulimia nervosa, cocaine dependence or psychosis [5]. There is strong evidence that psychoanalysis can be effective in borderline personality disorder and other personality disorders [6].  An interesting overview of evidence base can be found in the article 'The efficacy of psychodynamic psychotherapy' [7].

Lastly, by linking neurosciences with theory many studies show links to Freud's theories [8],  brain networks and conscious part of ego [9] as well as the presence of the unconscious in decision making [10]. In general, although neuroscientists find positive correlations, there are difficulties to provide scientific validity as a result of the diversity in research methodology and psychoanalytic approaches [11]. This is often the case with complex things - we cannot be 100% certain about many important questions.

Further one needs to think about the very individual approach of psychoanalysis - to what extent really can group based statistics applied to the development of psychoanalytic theory and treatment of a particular patient? If at this point in time we tend to rely only on evidence that can be expressed in numbers and we try to convert the human experience in numbers, such as using any Likert type scale - is that experience adequately reflected in the numbers we have obtained, or are we allaying our anxiety about lack of numbers and are missing something more important? These might seem theoretical questions, however they clearly are not when we are trying to help a patient. If explaining numbers were the treatment, life would be far easier and our speciality - more like Orthopaedic Surgery.

Types of psychoanalytic approaches

You may notice that there is not a central textbook of psychoanalysis. There are theoretical orientations that accentuate different aspects of theory. If we start chronologically, there is Ego Psychology - which focuses mainly on the conflicts  between the demands and drives of the intrapsychic agencies id, ego and superego and defences employed against anxieties stirred up by those conflicts. Object Relations school emphasises the importance of internalised relationships between people, the prototype being the relationship between the mother (the object) and the infant (the self).Self Psychology looks more at how external relationships help maintain one's self-esteem and self-cohesion. Attachment theory focuses on the impact of the caregiver's capacity to observe and respond in an attuned way thus shaping the development of the child [12]. Then major directions not to be forgotten are Jung's Analytical Psychology - a split from Freud's psychomiscanalysis long time ago and French Lacanian analysis that is closely based on Freud and semiotic aspects of language. History of development of psychoanalysis might perhaps be best appreciated through essays showing development of national associations in the book "100 Years of the IPA" [13].

Freud began the journey of psychoanalysis as an attempt of neurological understanding of patmiscients, but in a few years the impossibility of this task became clear. Today there are interesting developments correlating the findings of neuroscience with the clinical and theoretical findings of psychoanalysis. A group of researchers and analysts has called the movement Neuropsychoanalysis  [14].

Neuropsychoanalysis may hold a particular appeal to doctors - our medical training gives us more understanding of the workings of human biology. It is to be noted that neuropsychoanalysis is not a clinical method as such.  One does not treat patients through explaining psychoanalytic  or other theories; it is rather part of the background knowledge for the analyst that may help to understand the patient better and thus, perhaps, to find the right words at the right moment to help the patient to become aware of something and change.

Is it worth it?

The short answer is a definite yes, but it depends on one's perspective. The analyst has to grapple with universal aspects of human existence.  That often includes not quite knowing for sure what to do; it certainly has a failure rate, but it's success can be very fulfilling. It enriches one's life immensely, but it can be seen as quite an exclusive approach for the obvious reasons of time and money investment. However psychodynamic therapies are all based on psychoanalytic methodology therefore you could reasonably see analysis as a high-end method of psychotherapy spectrum and an engine for their further development.

I personally think that the way psychoanalysis works is by making one's thinking more complex, more able to see and feel what has not been possible before. If our premise is that part of the thinking process is unconscious, yet impacts strongly on  what we do, we may include feelings or feeling motivated thinking processes among those affected by analysis. In a simple way the idea behind this is that in order to talk we have to think and feel and what we think and feel is related to what we do.

Psychoanalysis is hard work - both for the patient and the analyst, but the reward is the enrichment of life - for both.

A Visual Example

If you would like to get a visual representation of what it might be like to be on the analyst's couch you can look at this video. I should warn you - it is a bit schematic and does not by far convey the gamut of experience that psychoanalysis really is, but it still is a serviceable visual illustration:

Gabbard video

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