Psychoanalytic Psychotherapy: Basic Technique

Basic Technique

The analysis of transference by the interpretation of resistance is important for the psychoanalytic psychotherapist. To promote the patient’s examination of the phenomena of transference and resistance, both the analyst and the therapist are guided by prin-ciples that establish a confidential, safe and predictable environ-ment geared toward maximizing the patient’s introspection and focus on the therapeutic relationship. The patient is encouraged to free associate, that is, to notice and report as well as she or he can whatever comes into conscious awareness (Tables 66.4 and 66.5).

Therapeutic neutrality and abstinence are related concepts. Both foster the unfolding and deepening of the transference, as well as the opportunity for its interpretation. The psychoanalytic psychotherapist assumes a neutral position vis-à-vis the patient’s psychological material by neither advocating for the patient’s wishes and needs nor prohibiting against these. The patient is en-couraged in the therapeutic relationship to develop the capacity for self-observation. Neutrality does not mean nonresponsive-ness; it is nonjudgmental nondirectiveness.

Abstinence refers to the position assumed by the psychoan-alytic psychotherapist of recognizing and accepting the patient’s wishes and emotional needs, particularly as they emanate from transference distortions, while abstaining from direct gratifica-tion of those needs through action. Abstinence is a principle that guards against the therapist’s gratification at the patient’s ex-pense. For example, as the treatment experience deepens into a more consolidated transference neurosis, there may be a strong tendency by the patient to experience the therapist as the impor-tant person in the patient’s life around whom the characteristic conflictual issues are manifested. By maintaining a neutral and abstinent position with respect to the patient’s needs and wishes, the psychotherapist creates a safe atmosphere for the experiencing and expression of even highly charged affects, the safety required for the patient’s motivation for continued therapeutic work. The position held by the psychiatrist is neither sterile nor overstimu-lating and promotes the establishment of a meaningful therapeu-tic relationship.

The rule of free association dictates that the patient should verbalize to the best of her or his ability whatever comes into awareness, including thoughts, feelings, physical sensations, memories, dreams, fears, wishes, fantasies and perceptions of the analyst. Whereas at first glance this requirement appears to be unscientific, in fact, the psychiatrist and patient quickly come to appreciate that no thought or feeling is random or irrelevant but rather that all mental content is relevant to the patient’s emotional problems. Indeed, much productive therapeutic work is focused on those instances when the patient is not able to speak about what is on his or her mind.

Many psychoanalytic psychotherapists also use the tech-nique of dream interpretation, although recently there may be less emphasis on this. Freud placed great emphasis on the inter-pretation of dreams because he discovered that such a technique provided insights into the working of the unconscious. In a simi-lar fashion, slips of the tongue, jokes, puns and some types of forgetfulness are attended to carefully by the therapist because they are nonsleep activities that also provide insight into the pa-tient’s unconscious mental processes. Good technique does not necessarily include pointing out to the patient these events each time they occur, for they may often be a source of intense embar-rassment. Rather, the slips are noted as helpful data in assessing the patient’s inner thoughts.

All of these techniques are embedded in a unique manner of listening to the patient’s verbalizations within the context of the treatment situation. In particular, two related but specific compo-nents initially attributed to the listening process are worthy of note. First, the concept of the evenly hovering or evenly suspended attention implies that listening to the patient requires of the thera-pist that he or she be nonjudgmental and give equal attention to every topic and detail that the patient provides. It also embraces the notion that the effective therapist is one who can remain open to her or his own thoughts and feelings as they are evoked while listening to the patient. Such internal responses often supply im-portant insights into the patient’s concerns. Secondly, empathic listening is of equal importance to both parties. Empathy permits the patient to feel understood, as well as provides the therapist with a method to achieve vicarious introspection. Indeed, one of the major contributions of self-psychology has been the identifi-cation of empathic listening and interpretation (the immersion by the therapist into the subjectivity of the patient’s experience) as basic to the methodology of psychoanalysis and psychoanalytic psychotherapy (Kohut, 1978, 1971). Interferences to successful empathic listening are often the product of countertransference reactions, which should be suspected whenever, for example, the therapist experiences irritation, strong erotic feelings, or inatten-tion during a treatment session.