What is Psychoanalytic Psychotherapy?
It is customary to define psychotherapy in a broad fashion as being composed of three distinct components: a healing agent, a sufferer and a healing or therapeutic relationship (Frank and Frank, 1991). Strupp (1986) specified that psychotherapy is the systematic use of a human relationship for therapeutic purposes of alleviating emotional distress by effecting enduring changes in a patient’s thinking, feelings and behavior. The mutual engagement of the patient and the psychotherapist, both cognitively and emotionally, is the foundation for effective psychotherapeutic work.
Whereas there are many different types of psychotherapy (Figure 66.1), the core task of the psychoanalytic psychothera-pist is to make contact with and comprehend, as thoroughly as possible, the patient’s subjective inner world to engage in an analytical (i.e., interpretive) conversation about it (Ornstein and Kay, 1990). This core task implies that all psychoanalytic psy-chotherapies may be further defined in terms of three operations: accepting, understanding and explaining (Ornstein and Ornstein, 1985) (Table 66.1). First, and more specifically, the therapist must engage with the patient by accepting the subjective experience of the patient’s emotional pain and conflict. This is achieved through the establishment of a therapeutic dialogue based on an empathic, nonjudgmental rapport. Secondly, within the process of listening to, and feeling with, the patient, the therapist will be-gin to develop an understanding of the intricacies of the patient’s plight. Much of what the therapist observes may at first remain outside of the patient’s conscious awareness, manifested in the form of reenactments and reliving of earlier experiences withinthe therapy, rather than in deliberate, conscious, descriptive com-munication. Last, by the sharing of this beginning understanding with the patient through a simultaneously empathic and interpre-tive mode, both arrive at a deeper appreciation for the genesis of, and the reasons for, the patient’s symptoms. The shared relation-ship in which understanding is gained is no less instrumental in achieving change than are the insights and modified perceptions that may result from the psychotherapeutic experience.
It is appropriate to conceptualize psychoanalytic psycho-therapy as being on a continuum of expressive to supportive (Luborsky, 1984; Gabbard, 1994). Traditionally, to the degree that psychoanalytic psychotherapy has focused on the recovery of repressed psychological material, it has been called “expressive” and has been distinguished from the supportive psychotherapies which have concentrated on the shoring up of certain defense mechanisms. This implies that any given treatment might employ more or less expressive and supportive interventions, depending on what is transpiring within the psychotherapeutic process. An important skill of the psychoanalytic psychotherapist is then the ability to employ the appropriate balance of both expressive and supportive interventions as dictated by the needs of the patient. Finally, the conceptualization of an expressive–supportive con-tinuum also facilitates the establishment of therapeutic goals, in-terventional plans and indications for individual psychoanalytic psychotherapy (Gabbard, 1994) (Table 66.2).
The theoretical concepts that derived from the theory reviewed constitute, more or less, the assumptions behind all psychoanalytic psychotherapy. These include, most im-portantly, the role of the unconscious; the centrality of transfer-ence; the characterological defense mechanisms; and the resistance to self-awareness and thereby to progress in the therapeutic setting. Of secondary importance, but nevertheless closely related to the unconscious, is the concept of psychic determinism, namely, that people behave in specific ways for specific reasons. No experience or memory, according to psychoanalysis, is ever lost but resides in the unconscious, which continues to influence current and future ways of experiencing feelings, thoughts and behaviors. Advances in cognitive neuroscience have supported the notion that many sig-nificant experiences throughout life remain outside of awareness.