Understanding Psychoanalytic Therapy

Psychoanalytic psychotherapy is a long-term talking therapy. It works with psychological difficulties that have been present for many years, often with roots in early life, rather than with a single current symptom.

The approach grew out of the work of Sigmund Freud and has been developed and revised by clinicians and researchers ever since. It connects a person's earlier experience with their present difficulties, on the premise that understanding one's own patterns gives more room to choose differently.

Table of Contents

What is Psychoanalytic Therapy, and How Does it Work?

How does Psychoanalytic Therapy Differ from Other Forms of Therapy?

What Does Psychoanalytic Psychotherapy Help With?

The Benefits and Limitations of Psychoanalytic Therapy

Is Psychoanalytic Therapy Suited to You?

Next Steps for Pursuing Psychoanalytic Therapy

Conclusion

Key Takeaways

FAQ

References

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What is Psychoanalytic Therapy, and How Does it Work?

What is Psychoanalytic Therapy?

Psychoanalytic therapy is a form of talking therapy that works with thoughts, feelings and memories that a person is not fully aware of, and with the way earlier relationships continue to shape adult behaviour. Its aim is greater self-understanding, and through that, more freedom in how a person relates to others.

The work is directed at longstanding patterns and unresolved conflicts that keep producing distress. It proceeds through open, unstructured talk about thoughts, dreams, memories and the relationship with the therapist, so that a person can come to recognise those patterns as they operate.

Psychoanalysis and Psychoanalytic Psychotherapy are not the same thing

The two terms are often used interchangeably, and this causes confusion. Psychoanalysis proper is intensive: commonly three to five sessions a week, often with the patient on the couch, conducted by a practitioner who has completed a formal psychoanalytic training, which includes a personal analysis and supervised clinical work. Psychoanalytic (or psychodynamic) psychotherapy applies the same body of theory and technique at a lower frequency, usually once or twice weekly and face to face.

Frequency, setting and training differ, and so does the research base. Most published outcome research concerns psychodynamic psychotherapy rather than full analysis. Where this article refers to research findings, it says which of the two is meant.

The Therapeutic Process

Sessions have little structure by design. The patient is invited to say whatever comes to mind without editing it into a report, a method known as free association. What emerges tends to include material the person had not planned to raise.

Four elements of technique are usually named as central to the method: interpretation, the analysis of transference, technical neutrality, and the therapist's use of their own countertransference [2].

• Transference. Old patterns of relating do not stay in the past; they show up in the consulting room, in how the patient experiences and treats the therapist. Because these patterns are live and observable there, they can be examined as they happen rather than only recalled.
  
• Resistance. People come to therapy wanting change and at the same time avoid it. Silences, lateness, changing the subject and sudden loss of interest are treated as material to be understood, not as failures of cooperation.
  
• Interpretation. The therapist puts into words a connection the patient has not yet made, and does so tentatively, at a point where the patient can make use of it.
  
• Countertransference. The therapist attends to their own emotional responses in the session and uses them as information about what is happening between the two people, rather than acting on them.
  
• The frame. A fixed time, a fixed fee, a set frequency and clear boundaries around contact between sessions. The frame is not administrative housekeeping but a stable condition against which a person's reactions become legible, which is why departures from it are discussed rather than simply accommodated.
  
• Dreams. Dreams may be brought and worked with as one source of material among others. In contemporary practice they are not the centrepiece of the method that popular accounts suggest.

A worked example: someone finds that each of their relationships has been with a partner who was emotionally unavailable. Over time in the therapy, a picture assembles: a parent whose attention had to be earned, and an expectation formed early that love and unavailability go together. That expectation also appears in how the person waits for the therapist to withdraw. Naming it where it is happening is what makes it something other than an idea about oneself.

How does Psychoanalytic Therapy Differ from Other Forms of Therapy?

Psychoanalytic therapy works with processes outside a person's awareness and with the history behind current difficulties. It is open-ended, and it treats the relationship with the therapist as a source of information in its own right. Other approaches, cognitive behavioural therapy among them, are typically time-limited and organised around identified problems, agreed tasks and current symptoms.

The difference is one of aim and method, not of merit. Which approach fits depends on the difficulty, the person, and what they are looking for.

What Does Psychoanalytic Psychotherapy Help With?

Psychoanalytic psychotherapy is generally considered where difficulties are longstanding, where they recur across a person's relationships and working life, and where shorter symptom-focused work has been tried without the change holding.

A Cochrane review of 33 trials involving 2,173 participants found that short-term psychodynamic psychotherapy produced modest to large improvements across a range of common mental disorders compared with control conditions. The review authors also state that these findings should be read with caution: some gains lost statistical significance at long-term follow-up, and the trials varied considerably in how the therapy was delivered [1].

Difficulties for which it is commonly offered:

• Personality disorders. Enduring difficulties in how a person experiences themselves and relates to others, which cause distress or repeated trouble in their relationships and work. Conditions such as borderline personality disorder and narcissistic personality disorder are among the areas where psychoanalytically informed treatments have been developed and studied.
  
• Persistent depression or anxiety. Where depression or anxiety has not shifted with shorter treatments, or returns each time it is treated, longer-term work on the conflicts that sustain it may be considered.
  
• Physical symptoms with a psychological component. Where physical complaints are bound up with emotional difficulty, the therapy takes the symptom seriously and works on what it may be carrying. Medical assessment comes first and continues alongside.
  
• Early trauma. Experiences from early development that shape how a person expects to be treated and what they can bear to feel. Work of this kind is paced carefully; trauma-focused treatments are also available and are sometimes the better starting point.
  
• Long-standing emotional difficulties. Difficulties that other forms of therapy have not resolved, where a person wants to understand what keeps producing them.
  
• Complicated grief. Where a loss has not settled over time and has become bound up with who the person takes themselves to be.

Psychoanalytic psychotherapy is not usually the first response to an acute crisis, to active psychosis, or to a situation needing immediate safety planning or medical treatment. Those need attention first.

The Benefits and Limitations of Psychoanalytic Therapy

What the approach offers

• Scope. It works with the whole pattern rather than one presenting symptom.
  
• Aim. It is directed at change in longstanding patterns rather than at rapid symptom relief.
  
• Attention to what maintains the difficulty. The work addresses the conflicts and expectations that keep a difficulty in place, not only its effects.
  
• The relationship as a working tool. The therapeutic relationship is itself part of the method, which allows patterns to be examined while they are happening.

Limitations and costs

• Time. Psychoanalytic psychotherapy usually means one or two sessions a week sustained over a long period. Psychoanalysis means considerably more.
  
• Pace. Change is generally gradual, which does not suit a person who needs relief from a specific symptom soon.
  
• Difficult material. The work involves speaking about things that are painful or shaming, and periods of feeling worse before feeling better are common.
  
• Cost and access. The frequency and duration make it expensive, and in many countries it is not funded by public health services or medical insurance. Availability varies widely by country and by city.
  
• The evidence base. Outcome research on psychodynamic psychotherapy is smaller and more variable than for some shorter treatments, and trials differ in how the therapy was delivered [1]. Full psychoanalysis has been studied less than the once- or twice-weekly form.

Is Psychoanalytic Therapy Suited to You?

These are the considerations most worth weighing, and they are worth discussing with a therapist rather than settling alone:

• Willingness to look. Whether you want to examine feelings and patterns that may be uncomfortable to acknowledge.
  
• Practical commitment. Whether a weekly or twice-weekly session is workable in your circumstances, over a long period, and affordable at the fees quoted to you.
  
• What you want from treatment. Whether you are looking for relief from a specific symptom, which other approaches address more directly, or for an understanding of something that keeps recurring.
  
• Structure. Whether you prefer a therapy with sessions organised around agreed tasks, or can work in a less structured setting.
  
• Current circumstances. Where there is an acute crisis, an untreated medical condition, or a need for immediate support, that is addressed first. Longer-term work can follow.

If you are unsure, an initial consultation exists partly to answer this question. A therapist should be willing to say when they think another approach would serve you better.

Next Steps for Pursuing Psychoanalytic Therapy

• Check registration and training. Therapists should be registered with the statutory or professional body that regulates practice in your country. For psychoanalysis and psychoanalytic psychotherapy specifically, ask which institute the person trained at and whether it is recognised by a national or international psychoanalytic association. Search the TherapyRoute directory to find practitioners in your area.
  
• Ask about the practicalities early. Fee, frequency, session length, the policy on missed sessions, and whether there is a waiting list. These shape whether the treatment is possible for you.
  
• Have an initial consultation, or more than one. This is an assessment in both directions. You can meet more than one therapist before deciding. A workable relationship matters, and if it does not feel right after a fair trial, saying so is legitimate and can itself be discussed.
  
• Talk about what you are hoping for. Not every difficulty needs this treatment, and a good assessment will say so.

Conclusion

Psychoanalytic therapy is a slow, demanding and relatively expensive treatment, aimed at difficulties that have proved durable. It asks for time and a tolerance for uncertainty, and it offers no guarantee of a particular result. Nor does any other therapy.

What it does offer is a sustained and careful examination of patterns that keep repeating, conducted in a relationship where those patterns can be seen at work. Whether that is the right use of a person's time and money is a question best put to a clinician who has met them.

Key Takeaways

• Psychoanalytic therapy works with processes outside a person's awareness and with the history behind present difficulties.
  
• Psychoanalysis and psychoanalytic psychotherapy are related but distinct: they differ in frequency, setting, practitioner training and research base.
  
• Transference, resistance, interpretation, countertransference and the therapeutic frame are the working elements of the method, not dream analysis alone [2].
  
• A Cochrane review found modest to large gains for short-term psychodynamic psychotherapy across common mental disorders, with the authors advising caution given variability between trials and some loss of effect at long-term follow-up [1].
  
• It is a long, costly treatment and is not the right first response to an acute crisis.

FAQ

How long does Psychoanalytic Therapy typically last?

Sessions are usually 50 minutes. The treatment itself is open-ended and commonly runs for a year or more, sometimes several years, depending on the difficulty and what the person is working towards. Some therapists offer a time-limited psychodynamic contract of a set number of sessions instead.

What is the difference between psychoanalysis and psychoanalytic psychotherapy?

Psychoanalysis is typically three to five sessions a week, often using the couch, and is conducted by someone who has completed a formal psychoanalytic training. Psychoanalytic psychotherapy applies the same theory and technique at once or twice weekly, usually face to face.

Can Psychoanalytic Therapy help with anxiety and depression?

It may. A Cochrane review of 33 trials found modest to large gains for short-term psychodynamic psychotherapy across common mental disorders, including depression and anxiety, compared with control conditions, while cautioning that the trials varied and that some gains were no longer statistically significant at long-term follow-up [1]. Other treatments have been studied more extensively for these conditions, and which to choose is a matter for assessment.

Is Psychoanalytic Therapy suitable for everyone?

No. It requires a sustained commitment of time and money, and it is not the appropriate first response to an acute crisis or to a condition needing immediate medical treatment.

Are Freud's theories still relevant today?

Contemporary psychoanalysis is not the same as Freud's. A number of his specific claims have been abandoned or substantially revised over more than a century of clinical work and debate. Several organising ideas, among them unconscious mental life, conflict, defence and transference, remain central to how psychoanalytic clinicians work.

What qualifications should a Psychoanalyst have?

Titles and their legal protection differ from country to country. As a rule, a psychoanalyst holds a prior professional qualification and registration, and has then completed a training at a recognised psychoanalytic institute comprising theoretical study, a personal analysis, and supervised clinical work over several years. Ask which body registers the practitioner and which institute they trained at, and check that body's public register.

References

[1] Abbass AA, Kisely SR, Town JM, Leichsenring F, Driessen E, De Maat S, Gerber A, Dekker J, Rabung S, Rusalovska S, Crowe E. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews, 2014, Issue 7. cochrane.org

[2] Kernberg OF. The four basic components of psychoanalytic technique and derived psychoanalytic psychotherapies. World Psychiatry, 2016;15(3):287-288. pmc.ncbi.nlm.nih.gov