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What Is Psychoanalytic Psychotherapy?

Psychoanalytic Psychotherapy

Psychoanalytic PsychotherapyPsychoanalytic psychotherapy (also called psychodynamic psychotherapy) is a contemporary form of treatment for mental health issues that has evolved from its roots in psychoanalysis over the last 100+ years.

This form of treatment emphasizes a comprehensive understanding of the client (“patient”) as a person, as opposed to following a strictly symptom-oriented approach. By considering the importance of a person’s life history and their capacity to take ownership of their choices, psychodynamic therapy works toward long-term growth and change.

The patient develops an honest and personal understanding of who they are, what they desire from their lives, and how they can effectively pursue these goals. While gaining insight, understanding, and acceptance, the patient also develops improved interpersonal skills vis-à-vis their relationship with the therapist. Research has shown that the therapeutic relationship (alliance) is a key factor in any psychotherapeutic success (Wampold et al., 1997). As a microcosm of the patient’s life, the therapeutic relationship has the unique potential of promoting an exploration of sensitive and important questions that may not be possible in any other context. Likewise, the therapist’s focus is determined by the best interests of the patient. The specifics of psychoanalytic psychotherapy are unique to the person as are the goals of the treatment. Overall, the intent is for the therapist to help the patient enhance their life with minimum conflict and stress, while also maximizing their sense of self-efficacy.

Are psychoanalytic therapies really all about sex, mothers, and toilet training?

There are a lot of misconceptions and myths about psychoanalytic theory and psychodynamic therapy. The approach views the person both historically and in terms of their present life. Scientific research has confirmed the importance of early childhood experience and the quality of early relationships as determining factors for shaping personality (Shedler, 2010). What makes each of us unique is how we have navigated the trials and challenges in our histories.

From a psychodynamic perspective, sex is a broad concept that encompasses all of a person’s biological predispositions. The importance of understanding sexuality is largely to recognize the basic life drives and needs. Over time and maturation, these drives differentiate into the pursuit of pleasure, comfort, love, and personal identity. Mothers, of course, typically provide our first experience of love and acceptance and set the prototype for all subsequent intimate relationships. And, while toilet training may seem like a strange event for extensive concern, it represents another prototypical experience regarding socialization. Toilet training may be illustrative of the quality of a child’s experience with being socialized into the standards and expectations of the culture. Most importantly, at the time psychoanalysis was being created, toilet training was an indicator of harsh and punitive child-rearing practices. So, while out of context, these concepts can sound bizarre or archaic, they have come to be recognized as important metaphors for describing a young person’s challenges with the world.

Will a psychoanalytic psychotherapist offer advice or solutions for problems?

In most cases people are intelligent and resourceful enough to solve their life’s problems, but may be blocked by fears, thoughts, and memories that are obstacles. In psychoanalytic therapy, patients learn to identify those obstacles and explore what can be done to move beyond them. A person’s strengths and creativity are built upon so that expertise in living becomes part of the patient’s skill set.

How long does psychoanalytic psychotherapy take?

Psychoanalytic psychotherapy is not time-limited. The length of therapy is a mutually determined issue, based on the patient’s needs and desires. As everybody has different needs and issues to consider, it would be presumptuous to dictate how long a therapeutic process should take. On the other hand, the therapist recognizes and addresses when therapy is no longer necessary or counter to a person’s needs. The goal of any effective psychotherapy is to become no longer necessary.

Who should seek psychoanalytic psychotherapy?

People best suited for this form of therapy are those with a sincere interest in knowing themselves better. The prospective patient should be willing to examine their thoughts, actions, and emotions honestly and openly in a trusted relationship with a qualified professional. While “quick-fixes” are not typical or even the intent of this form of therapy, many patients find significant improvement within weeks of beginning treatment.

Additional Resources

For more information on the basics of psychoanalytic psychotherapy, see the online course Classical Psychoanalytic Theory.

References

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 66(2), 98-109.

Wampold, B. E., Modin, G., Moody, G., Stitch, F., Benson, K., & Ahn, H. (1997) A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically “all must have prizes”. Psychological Bulletin, 122, 203-215.

Isn’t Psychoanalysis Dead?

Psychoanalysis

PsychoanalysisI heard the question again just last week, this time from an undergraduate in my Abnormal Psychology class. I’ve heard it many times over the years, from colleagues and grad students as well. I had also been taught, all through college and throughout graduate training, that no one considered Freud’s work anymore. I suspect that most Americans have been taught the same.

I left my graduate training, armed with all the “best practices” in “empirically-based” primarily cognitive and behavioral techniques. I recall arguing with colleagues who mentioned psychoanalysis or psychodynamic approaches that research had not demonstrated their effectiveness. When one colleague commented that some patients had found them to be helpful, I privately wondered about his competence as a clinician.

Then I met Mary. She had been referred to me for depression. No problem, I thought. Lots of techniques had been demonstrated empirically to be effective in treating depression. When she asked if she could leave a cup in my office because medication had made her mouth dry, I had been trained to think only in terms of the practicality of having a cup available. But I quickly came to understand that such questions, and many others that followed, had far deeper significance—dependency needs, unconscious tests regarding acceptance, attempts to challenge boundaries, splitting. Her feelings—and relationship with me—were filled with turmoil. Idealizations swung to devaluations, and back again. She raged and despaired. She challenged all of my beliefs about the therapeutic process as manageable by the “right” charts and techniques.

I feel so fortunate to have met Mary early in my practice. To this day, I do believe that cognitive and behavioral techniques have merit, but I also see the enormous value of psychodynamic psychotherapy, as well as humanistic, emotion-focused, supportive, and countless other approaches. Humans are very complex creatures. Each therapeutic approach provides us with a lens through which to view a person. I believe we have a responsibility to become as familiar as we can with multiple ways of viewing each case, so that we can best address our patients’ needs in the moment, and as they evolve.

I was heartened to hear a comment from another student later in the week that she appreciated that I included psychoanalytic approaches when talking about treatment options with patients. Interestingly, she is a foreign exchange student from a region of the world where such approaches are generally understood to be of value.

To quote Eric Kandel, neuroscientist and Nobel Laureate, “Psychoanalysis still represents the most coherent and intellectually satisfying view of the mind” (American Journal of Psychiatry, 1999).

Resources

For the basics of psychoanalytic theory, see the course Classical Psychoanalytic Theory.  For more on the psychotherapeutic relationship, you may find Psychodynamics of the Therapeutic Relationship interesting.

The Value of “Having Your Head Examined”

Psychotherapy

PsychotherapyThe profession of psychotherapy has been around for over 100 years, with less formal versions of personal consultation going back to biblical times.  So why is it that the voluntary seeking of psychotherapy can be such a polarizing issue?   

Skeptics of psychotherapy cast doubts on the effectiveness of “talk” to change anything in a substantive manner.  Human beings are talkative creatures, so what is so special about talking to a psychotherapist rather than to a hairdresser, bar tender, cab driver, or next-door neighbor?  “If all therapists do is talk, then I can get that anywhere, and for a lot less than $150 per hour!”  

But talking is only one part of the picture.  An even more significant aspect of psychotherapy is the therapist’s capacity to hear what is being said—not just with words, but also in a larger implicit sense—hearing the meaning of a person’s truth.

Some advocates of psychotherapy might argue that it has changed their lives, saved their marriages, or even freed them from a life of abuse.  

What does seem clear to me though is that many people are afraid of psychotherapy.  Considering how therapists get portrayed in movies or the embarrassing presentation of media psychologists, there seems to be good reason to fear them.  I am often asked if psychotherapists are motivated by their own deep-seated issues and if they are as “crazy” as the people that they portend to treat?  My answer is simply . . . of course!  Being human is, in itself, a crazy proposition.  We live in an artificial world of our own invention by rules we make up, and we kill ourselves needlessly in wars, with drugs, on highways, in airplanes, and sometimes for pleasure.  There is good reason to think humans are crazy!

Yes, we do good things too, and we invented science and ethics and laws.  But while it is easy to be seduced into exalting the remarkable advances produced by the human race, our fellow (nonhuman) creatures may have a profoundly different opinion of us—if we could only hear them speak!  Humans have one foot in a virtual world of seemingly limitless creativity that seems wonderful, if not artificial, and the other in a biological reality, with specific needs and limitations.  People need to be nurtured, for instance, by another person who will validate their existence and uniqueness.  (Think about how painful it can feel to be ignored, or have your feelings and thoughts dismissed and devalued).  

Perhaps the most valuable contribution made by the profession of psychotherapy has been to create an industry designed to help persons retain their connection to their humanity.  In spite of all we have invented, we remain fragile living organisms, clinging to each other for survival—a reminder that there is no substitute for real human contact.  

With dozens of forms of psychotherapy to choose from, what they all have in common is that they provide a private, protected space, where the challenge of being alive can be acknowledged and supported by another who respects and listens to the struggle for sanity.

A good resource for clinicians for more information on the complexities of the therapeutic relationship is the course Psychodynamics of the Therapeutic Relationship.

The Importance of Consultation Among Psychotherapists

 

Consultation for PsychotherapistsConsultation for Psychotherapists

 

 

 

 

 

I tell my graduate students that beyond all the academic exercises of reading, writing, and research, the two most important skills for a competent psychotherapist to master are the capacities for being alone and the tolerance of not knowing.

Ironically, even though a psychotherapist spends many hours listening and talking with patients about the most intimate details of their lives, the therapist is a virtual stranger who assumes a role that is temporary and transient. The therapist certainly is drawn into an intense emotional experience, but, ultimately, as a visitor.

When the sessions end, any residual effects must be contained or resolved so as not to contaminate his/her role for the next patient or to be brought home to one’s family and friends. Our commitment to confidentiality is also a commitment to a private and personal aloneness.

Very few occupations require a person to remain as silent about one’s life as does the psychotherapist, except perhaps, for the profession from which it is derived—the priesthood.  We do, however, have the option of seeking consultation and/or supervision where, under a similar cloak of privacy, we can admit to our confusion and find refuge from our isolation.

The education of a psychotherapist is continuous, yet no amount of reading or research is sufficient preparation for a suicidal adolescent, the abused child, or the dying elderly. In the aloneness of these challenges, the therapist faces the limits of one’s potency in the task of helping a fellow human survive. 

Connecting with a colleague is a service, I believe, that is owed by every member of this profession, to every member. The remarkable technology we have can allow us to form affiliations with relative ease and unlimited potentials.

I invite any mental health practitioner who reads this blog to consider reaching out and forming connections, starting study groups and peer supervision circles.

For more on the complexities of the therapeutic relationship, see Psychodynamics of the Therapeutic Relationship.

A Commentary on the State of Mental Illness in Contemporary Society

Psychiatric MedicationPsychiatric Medication

Television advertising for psychiatric medications seems to have become as regular as commercials for automobiles, miracle cookware, or cosmetics. We are shown beautiful young men and women enjoying their friends and family, as we are also told that they have major depressions, bipolar moods, insomnia, and other potentially debilitating conditions.

Certainly these ads help de-stigmatize mental illness by showing that anyone can suffer from psychiatric problems. They present an optimistic view of successful treatment, a healthy productive life, and the assurance of better living through chemistry. Appropriately, they provide the legal disclaimers that these medications might cause some side effects and are potentially life threatening, but the likelihood is probably small and the image of a potential cure is obviously seductive.

The Motivation Behind Psychiatric Medication Ads

But also consider what else may be motivating these ads. These are not products that anyone can go out and buy like a car, a non-stick pan, or anti-wrinkle cream. These are products carefully controlled by the FDA to be dispensed only by licensed medical providers with an expertise in psychiatric disorders.

The target audience is presumably people who are suffering from serious mental health complications and/or their family members. If the intent of the advertisers were to help people seek psychiatric care, they would be promoting clinics, counseling centers, healthy lifestyle choices, and sources of information, as seen in public service announcements. Instead, they are targeting a vulnerable population with an implied promise of a cure that is not really supported by scientific research.

This is not to say that psychiatric medications are not helpful–they clearly are.  But they are not curative. The ads promote the theory that psychiatric disorders have been proven to be medical illnesses, which is not exactly true. The ads further assert that the cause of these conditions is specifically known and that these medications will correct the imbalance or deficiency the person is plagued with—also not exactly true!

In my 30+ years as a clinical psychologist I have seem many patients benefit from the use of medications, but I have never seen a patient cured by medication.  The combination of medication, psychotherapy, and lifestyle change has the best likelihood of helping people survive and thrive, so why isn’t that being made more explicit?

What Are Psychiatric Medication Ads Really Promoting?

I believe that the subtext to psychiatric medication ads is the promoting of helplessness and dependency in the public. That is, the ads promote the position of the patient as defective, damaged, or victimized.

There is no question that people are biological creatures constituted by a remarkably complex physiology and neuroanatomy. People are also creative, imaginative, and intelligent creatures who experience life with a remarkable capacity for change and adaptation. Everything we do or think or feel is accompanied by changes in our physiology, biochemistry, and neuroanatomy, but that does not mean that these processes determine us. Rather, biological processes are descriptions of how we function.

An increase in neurotransmitter levels may enhance a mood, whether by ingesting a medication, or by engaging in meditative or pleasurable activities. The causal relationship between biochemistry and mental states goes in both directions. By taking active roles in improving their lives, people can foster a healing that extends to the deepest levels of their physical existence.

To equate the effects of a medication with the definition of a mental experience would be like saying that a headache is caused by an aspirin deficiency. The aspirin can help, but its absence is not the reason for the headache any more than lowered serotonin level is the reason for depression.  For those people who may have a genetic, or otherwise inborn tendency toward a depressive way of being, medications may prove to be a godsend. These people will also greatly benefit from being helped to reconsider how they manage their lives, relate to others, and pursue their dreams.

Our Potential In the World

Mental illness may be an inevitable consequence of the human endeavor to redesign nature into a world that is safe, fair, and rewarding. We cannot eliminate the reality of nature’s forces or its occasional cruelty and tragedy. As humans, we face the disappointments of elusive ideals and the limitations of our ability to control our destiny. We must also consider the extent to which the world we have created for ourselves may be responsible for eliciting what we call mental illness. We are not the world, only participants in it who have a potential to think, choose, and survive with the help of others.

Mindfulness meditation practices and psychotherapy provide alternatives that can improve well-being, without diverting attention from the individual’s role in defining his or her life’s journey.

To find online courses for continuing professional development in psychoanalysis and other areas of psychology, see our list of courses on promoting diversity, modern systems theory, psychodynamics, mindfulness, and more.

Thinking Like a Psychologist

Psychotherapy and Epistemology: Learning How to Think

Psychotherapy and EpistemologyPsychotherapy and epistemology–what do they have to do with each other?  Philosophy refers to how knowing happens as epistemology.  I would argue that addressing the process of knowing is at least as important for training psychotherapists as considering what is known.  Let me explain…

When I supervise graduate students who are training to be psychotherapists, I find the most challenging task is to teach them to think like a psychologist.  How does a psychologist think?  Or, more accurately, how do I think a psychologist should think? 

To me, the purpose of clinical psychology is to help mitigate human suffering to whatever degree we can.  In order to pursue that purpose, the psychologist has to understand the uniqueness of each patient’s suffering.  The patient is a person with whom we have a therapeutic responsibility and a person whom we are obligated to know and respect.

Knowing someone, especially someone who is a virtual stranger, such as a psychotherapy patient, is a formidable task.  We do not know someone by getting a list of facts.  Name, birthdate, place of birth, occupation, history of illnesses—these are all lists of categorical data, but they are not knowing.  We can only know someone by relating to them over time in a relationship.

In a relationship, we know someone by how we feel with them, what fantasies they stimulate in us, or how they communicate beyond words.  Being with another person allows us to become part of their (and our) creative process.  The key here is process…an ongoing interaction.

We are much better served by using verbs to describe relationships than by using nouns.  In fact, I would assert that mental disorders and pathologies are best understood as verbs as well.

Suppose, for a moment, that you wanted to get to know Vincent Van Gough.  Since he is dead, you couldn’t set up an appointment.  But you could read books about him, see a movie about him, or sit with a few dozen of his paintings and relate to them for a while.  I would suggest that, as a psychologist, you could get to know him very well from sitting with the paintings.  In fact, I would suspect that the books and the movie would be dangerously misinforming.  One does not need to be a trained art historian or critic to understand Van Gough from his paintings.  One needs to be able to be transformed by the perceptions and sensations created by the colors, swirls, and patterns.  The question you might have is whether these transformations are true and valid.  My answer is that they are as true and valid as one ever gets.  There is no ultimate truth to Van Gough any more than there is to you or me.

What is true is what we negotiate from our experience with one another.  And these truths are transient and evolving.  The truths we learn about someone are the products of our relationship.

In part, what we know is made up. We invent knowledge from information that is generated by our biological processes.  But it is not as if we just make it all up; rather we create information at a basic biological level that then gets transformed by complexes or networks of other biological processes that produce still more variations of information.  At some point, the product of these processes becomes a mental phenomenon that we refer to as thinking.  We link our thoughts together in patterns that are self-supporting and that afford us a sense of certainty or knowing.

In fact, much of everyday anxiety is caused by a lack of certainty or doubt that interferes with knowing.  Ask an anxious person why they worry and they can often tell you that they know that it doesn’t make sense, but that they “can’t help it.” Why not?  The thinking disrupts the links in the patterns of knowing and disrupts the certainty.  The result is to question what is known or to be anxious.

“What if…,” we think?  There are no limits to what we can imagine, but there are limits to what can be true.  Just because it can be thought doesn’t mean that the thought is true, but try to convince a worrier of that!  The dominance of our basic subjective position, our narcissism, can lead us to feel compelled to account for any thought as important simply because we thought it.

I doubt that most of us ever consider the epistemology with which we know.  We might be aware of certain beliefs or values and we might be aware of political or scientific theories that seem more right to us than others, but I doubt that we regularly consider the extent to which our knowledge is the product of a system for knowing.  We are most likely to entertain a challenge to our knowledge only as a last resort.

Even the onset of mental illness is not sufficient to cause us to rethink what we know.  I tell my graduate students that a patient’s psychopathology is the person’s best effort at staying sane.  A person is apt to make themselves crazy before they will lose their sense of certainty.  In fact, psychotics are quite certain about their delusions and hallucinations; it is we neurotics who worry and fret about what is true.

What is true, in any meaningful way to a person’s life, is always a subjective truth—what we “know to be true.”  This is a truth rooted in our sense of self—our being.  Scientific facts, religious truths, or mathematical proofs are only true to us when they have been incorporated into our being and embraced as our own.

Obviously, we have gone through quite an array of truths over the course of human history that were all touted as the unequivocal truths of their time.  Where did the Greek and Roman gods go?  They died when they didn’t have people to believe in them.  Why do we know that the Earth revolves around the Sun and not the other way around?  Because the mathematics for the former is much more simple and elegant.  Why do people go mad?  Because of abusive childhoods, biochemical imbalances, predisposing genetics, or socio-political persecution?  We are still struggling with that one!

Science is an epistemology, but only one of many.  The key to survival in nature is adaptability and diversity; likewise, the key to psychological survival is in adaptive and diverse epistemologies to help us learn to appreciate and respect the complexity of nature.

I am not arguing against science or for any particular epistemology for that matter.  Instead, I am hoping to inspire the reader to consider the basis and presuppositions that comprise one’s system for knowing.

Having spent nearly my entire life in education, either as a student or as a teacher, I am quite aware that we are rarely, if ever, taught how to think, but rather what to think.  I am also just as aware that what people benefit from most readily in psychotherapy is being emancipated from truths that are pathogenic and paralyzing.  These “truths,” however they may have been derived, can be redefined, diminished, or discarded for the sake of a person’s future mental health, but not without considerable resistance from that person’s loyalty to the “known.”

I welcome your thoughts.

~ Michael J. Gerson, PhD

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