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What is Psychoanalytic Psychotherapy?

By Enzo Sinisi

So you have been thinking of seeing a therapist but with so many different kinds of therapy to choose from you don't know where to begin. This article will shed some light on psychoanalytic psychotherapy and should help you decide if this approach is right for you.

What is it?
The term 'psychoanalytic psychotherapy' can refer to a spectrum of talking therapies ranging from once-weekly face-to-face psychodynamic therapy all the way to full-blown five times weekly, on-the-couch psychoanalysis. The reason these therapies are grouped together is their shared recognition that we are not always aware of why we do the things that we do (the unconscious), that while we want to change we also want to stay the same (resistance), and that unrecognised feelings and effects of past experiences influence how we see and relate to the world today (transference).

Psychoanalytic therapies have their roots in the work of Freud and his colleagues, but have evolved substantially with advances in neuroscience, clinical research and the changes in society over the past 100 years. Just as your GP won't be applying leeches at your next visit, so your therapist probably won't try convincing you that all your problems stem from your unconscious desire to kill your Father. Well, not unless it's true.

How does it work?
Psychoanalytic therapies work firstly by creating a safe, confidential and reliable space in which you are encouraged to share all of your thoughts and concerns without being judged or criticised. The therapist listens carefully and tries to get to know you on a deep emotional level, but this really is a mutual project and the two of you will work together to understand the deeper significance of what you might be saying, thinking, feeling and doing.

Some of the guiding principles include; the recognition that all behaviour is meaningful when considered in the context of our whole life, that we use several tricks to avoid dealing with difficult things (doesn't really work), and that we often rely on strategies that were effective in childhood but which cause difficulties for us as adults.

The therapeutic relationship is one of, if not the, most important elements of any therapy, but it is particularly important in psychoanalytic therapies. The way it unfolds offers a window into our unconscious life. We all bring aspects of our past relationships and inner realities into our current relationships, and so psychoanalytic therapies use the therapeutic relationship to identify and work through these issues.

Psychoanalytic therapy aims to provide more than advice or a supportive ear. It seeks to facilitate deep and lasting change within, and to contribute to overall psychological wellbeing. Hence, these therapies prefer to focus on the conflicts that prevent us from succeeding rather than on advising us on how to succeed. Similarly, they might aim to understand and resolve the underlying dynamics which cause our anxiety rather than teach us techniques to control anxiety.

If all goes well, this process will help you deepen your awareness of your actions and how your inner world influences your life, emotions and perceptions of yourself and others. This leads to further emotional maturity which in turn leads to improved relationships, self-esteem, confidence, creativity and greater fulfilment i.e. less symptoms like depression, anxiety, self-destructiveness, unstable emotions, feelings of isolation etc.

What happens during the sessions?
The first few sessions usually take the form of an assessment. During this time the therapist may ask questions about your life and troubles, or they may simply listen to what you have to say. Adolescents and children can find it difficult to express their thoughts and feelings, and so the therapist might help the process in these instances by asking them to draw something or to describe what they see in a picture. The purpose of these meetings is for the therapist to gain an understanding of the nature of the client's difficulties and whether a psychoanalytic approach will be of use. Once the therapist has a sense of the difficulty, they will share their thoughts and will make a recommendation. They may recommend short or long-term psychoanalytic therapy or they might suggest something else entirely and make a referral. This assessment phase also gives you a chance to decide whether you are comfortable working with this therapist. If the therapist recommends individual psychoanalytic psychotherapy and you accept, the next step will be to decide how often to meet and to set up regular meeting times. Meetings typically last 50min and take place at the same time each week. Continuity is very important for this kind of work. Many therapists will take a moment to discuss how they deal with practicalities such as payment, missed sessions, holidays and confidentiality. The actual therapy sessions will differ from the assessment sessions, and how the therapist approaches therapy will depend on their training and assessment findings. In short-term therapy, the therapist will usually remain involved and active. They ask questions, make challenges and keep sessions focused on the task. Therapists conducting longer term therapy are less active and leave most of the talking to you. The therapist will listen and over time guide you towards recognising patterns and considering the meanings of what is taking place and how it relates to your life challenges. Longer-term therapists might ask you to begin the sessions and to put all of your thoughts and feelings into words (even if they seem irrelevant, silly, or embarrassing). This will probably feel uncomfortable, but it allows things to surface which would not have otherwise. Some therapists might suggest that you lie on a couch with them sitting behind you. This set up makes it easier for you to look inwards and for the therapist to notice how your psychology colours the world around you.

Therapists usually limit the relationship to the therapy hour and refrain from disclosing personal information or making physical contact. This may feel unfriendly, but this stance has been shown to be most effective in the long run. It protects the professionalism of the relationship and allows important difficulties and feelings to surface which can reveal how you relate to others most clearly.

How long does it take?
Short-term psychoanalytic therapies last between 10 and 30 sessions. This approach is suitable for addressing things that are specific and clearly definable. For example, a phobia of using elevators that appeared several months ago soon after attending the funeral of a loved one. In these instances, a fixed number of sessions is usually be set out from the beginning, and the therapy is concluded once these sessions are complete.

Short-term therapies can be powerful, but they are usually not the best choice for general difficulties e.g. unstable difficult emotions, trouble sustaining relationships, long-term effects of sexual abuse, feeling empty or chronic inhibition. Current research also suggests that therapies which focus on symptoms (rather than whole people) are less beneficial and durable in the long runi.

Most psychoanalytic therapies aim for a high level of self awareness and emotional maturity. They ambitiously work towards altering longstanding personality patterns, and so are long-term by definition i.e. more than one year. Of course more severe or longstanding difficulties do generally require longer therapies, but this is not the only factor. Other factors include your level of commitment, and the aims that you set out to achieve (e.g. I just want to feel better vs. I want to get to the bottom of this, once and for all!).

How often should I attend?
Psychoanalytic psychotherapy involves attending regular sessions at least once per week. Although it is costly, it is worthwhile to seriously consider meeting more than once per week since greater frequency allows for deeper work to take place. More frequent contact helps the relationship to develop, and makes it easier for both you and the therapist to recognise and work on what unfolds. It also allows different elements to surface and this increases the scope of what can be achieved.

Does psychoanalytic therapy work?
The short answer to the question is Yes... but this needs to be qualified. Psychoanalytic therapies can help a person overcome significant issues, can reduce and even eliminate certain symptoms, can improve one's relationships, sense of self, and even work performance, creativity and motivationii. However, psychoanalytic psychotherapy is not magic. It involves hard work, does not cure all woes and will not lead to a trouble free and perpetually happy life.

The success of therapy will depend on all the factors involved i.e. the fit between you and the therapist, your motivation, dedication, and openness, the therapists experience and skill, and external factors such as time, resources, and support. Other important factors include your wish for self-understanding, a willingness to tolerate uncertainty, and your readiness to consider different points of view.

What does it help with?
Research has confirmed the effectiveness of psychoanalytic psychotherapy in addressing a variety of specific diagnosis including; mood disorders (e.g. depression), anxiety disorders (e.g. panic), eating disorders, traumatic stress disorders, dissociative disorders and personality disorders.

As you might have gathered, psychoanalytic therapists tend to be particularly interested in people and their personalities and not just specific psychiatric symptoms. This makes psychoanalytic therapy a good choice for people who don't have a particular diagnosis, but who might be troubled by more general difficulties such as recurring relationship troubles (e.g. fear of commitment), feeling unfulfilled or inhibited in life, identity difficulties, being addicted to work, or simply wanting to engage in personal growth.

How much is it?
Most practitioners are mindful of medical aid rates but fees can range between R300 and R700 (US$ 43-100) per session. Short-term therapists sometimes charge more than long-term therapists because long-term therapies are more difficult to sustain financially. Don't be fooled into thinking that fees necessarily reflect a person's level of expertise since it is not unusual to find a recently-qualified therapist asking for higher fees than someone with years of additional training and experience.

How to choose a therapist?
Psychoanalytic Psychotherapy is an advanced skill that is acquired through post-qualification training. It is important that the therapist you choose is adequately trained, experienced, supervised and registered with a psychoanalytic body as a Psychoanalytic Practitioner (preferably the South African Psychoanalytic Confederation). Registration as a Psychoanalytic Practitioner ensures that the therapist has had some psychoanalytic psychotherapy of their own. You can't learn this technique from books alone and you want a therapist who knows themselves and what it means to go through this kind of process.

By Vincenzo Sinisi, a Cape Town clinical psychologist in full private practice, July 2010.

[i] Waldron, S., Moscovitz, S., Lundin, J., Helm, F., & Jemerin, J. (2010). Evaluating the outcomes of psychotherapies: The Personality Health Index. Submitted for publication in Psychoanalytic Psychology.

Westen, D., Gabbard, G. O., & Blagov, P. (2006). Back to the future: Personality structure as a context for psychopathology. In R. F. Krueger & J. L., Tackett (Eds.), Personality and psychopathology (pp. 335-384). New York: Guilford.

[ii] Abbass, A. A., Hancock, J. T., Henderson, J., Kisely, S. (2006). Short-term psychodynamic psychotherapies for common mental disorders. The Cochrane Database of Systemic Reviews, 4:CD004687.

Anderson, E. M., & Lambert, M. J. (1995). Short-term dynamically oriented psychotherapy: A review and meta-analysis. Clinical Psychology Review, 15, 503-515.

de Maat, S., de Jonghe, F., Schoevers, R., Dekker, J. (2009). The effectiveness of long-term psychoanalytic therapy: A systematic review of empirical studies. Harvard Review of Psychiatry, 17, 1-23.

Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300, 1551-1565.

Fonagy, P. (2006). Evidence-based psychodynamic psychotherapies. In PDM Task Force (2006), Psychodynamic diagnostic manual (pp. 765-818). Silver Spring, MD: Alliance of Psychoanalytic Organizations.

Roth, A & Fonagy, P. (2005). What Works For Whom? 2nd Ed. The Guilford Press: New York.

Sandell, R., Blomberg, J., Lazar, A., Carlsson, J., Bromberg, J., & Schubert, J. (2000). Varieties of long-term outcome among patients in psychoanalysis and long-term psychotherapy: A review of findings in the Stockholm Outcome of Psychoanalysis and Psychotherapy Project (STOPPP). International Journal of Psychoanalysis, 81, 921-942.

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