What are the main ideas behind psychoanalytic therapy?

Psychoanalysis is a treatment based on the theory that our present is shaped by our past. We are often unaware of how experiences can affect us. Painful feelings can remain in the unconscious mind and influence our current mood and behaviour and contribute to problems with self-esteem, personality, relationships and work.

Because we are unaware of these forces, common problem-solving techniques – such as seeking the advice of friends and family or reading self-help books– often fail to provide relief.

Psychoanalysis helps a person take control of these influences by tracing them back to their origins and understanding how they have developed over time. This awareness offers the person the opportunity to deal constructively with the way these influences affect their current life.

Conditions treated by psychoanalysis

Some of the problems treated by psychoanalysis include:

• Depression
• Generalised anxiety
• Sexual problems
• Self-destructive behaviour
• Persistent psychological problems, disorders of identity
• Psychosomatic disorders
• Phobias
• Obsessive compulsive disorders.

The unconscious mind

According to psychoanalysis, the unconscious mind gives hints of the unacknowledged meaning of experiences in different ways. Such hints may include:

• Repetitive behaviours
• Topics that the person finds difficult to talk about
• Dreams
• Daydreams
• The nature of the patient–therapist relationship.

Psychoanalysis and psychotherapy

Psychotherapy is an umbrella term, which describes any form of treatment of the mind.

Psychoanalysis is a treatment based on studies of the conscious and unconscious human mind. All psychoanalysts have a primary qualification in psychiatry, psychology, social work or other health discipline. Well qualified researchers, educators and selected other professionals may also become psychoanalysts. Training standards for psychoanalysts are set by the International Psychoanalytical Association.

Psychiatrists are medically qualified doctors with postgraduate experience and training in treating mental illness, using both physical and some psychological treatments. Psychologists do not usually have a medical qualification, but have a degree in psychology and have studied mental processes and behaviour.

Finding a professional psychoanalyst

The title ‘psychoanalyst’ is not regulated by any Australian laws. This means that anyone can set up practice, even if they have no experience or training. It is important to find a psychoanalyst through a professional society.

Graduate psychoanalysts trained under the auspices of the Australian Psychoanalytical Society have had extensive clinical education. Candidates accepted for training must meet high ethical, psychological and professional standards.

The patient–therapist relationship

Psychoanalysis is a close relationship. The bonds that develop in the course of treatment create a safe environment for the person to reveal personal information.

The experience with the analyst is emotional as well as intellectual.For example, a person may have difficulty trusting their analyst. Discussing this may help them explore their problems with trust in their everyday life.

The analyst helps by fostering the bond with the patient and helping them interpret the meanings behind their thoughts. This can help the person refine, correct, reject and modify disturbing thoughts and feelings. During analysis, the person comes to terms with these insights, noting their influence on experience in daily life, in fantasies and in dreams.

By working with the analyst, the person can come to gain control over disabling life patterns and incapacitating symptoms. Over the course of time the person’sbehaviour, relationships and sense of self can change in deep and enduring ways.

The psychotherapy session

Regular treatment is needed to develop the closeness and intimacy required for this form of self-exploration. The patient sets their own pace and agenda for the treatment by saying everything that comes into their mind, to the best of their ability.

The setting for treatment is important. Regular session times usually last fifty minutes each week. This helps create a reliable environment in which a patient feels they can trust their psychoanalyst. An analysis may take months or years, because of the deep emotional work involved.

Patients are often asked to lie on a couch, which also helps create a setting of trust. However not all patients use a couch.

Most psychoanalysts will not take notes during a session with a patient. Taking notes could interfere with their task of listening and responding to the patient.

Where to get help

• Your doctor
• The Australian Psychoanalytical Society Tel. (03) 9500 2199
• Adelaide Institute for Psychoanalysis Tel. (08) 8364 5357
• Melbourne Institute for Psychoanalysis Tel.(03) 9882 1661
• Sydney Institute for Psychoanalysis Tel. (02) 9958 0889

Things to remember

• Psychoanalysis is a type of treatment based on the theory that our present is shaped by our past.
• The unacknowledged meaning of personal experiences can influence our mood and behaviour, and contribute to problems with relationships, work and self-esteem.
• It is important to find a psychoanalyst through a professional society.

Four aspects jointly determine the very essence of psychoanalytic technique: interpretation, transference analysis, technical neutrality, and countertransference analysis.

Interpretation is the verbal communication by the analyst of the hypothesis of an unconscious conflict that seems to have dominantly emerged now in the patient's communication in the therapeutic encounter. In general, interpretation of a defense or a defensive relationship initiates the interpretative process, followed by the interpretation of the context, or the impulsive relationship against which the defense was erected, and the analysis of the motivation for this defensive process.

Interpretative interventions may be classified into: a) clarification, by which the analyst attempts to clarify what is consciously going on in the patient's mind; b) confrontation, that is, tactful bringing into awareness nonverbal aspects of the patient's behavior; and c) interpretation proper, the analyst's proposed hypothesis of the unconscious meaning that relates all these aspects of the patient's communication to each other.

This condensing hypothesis is interpretation “in the here and now”, to be followed or completed with interpretation “in the there and then”, that is, the genetic aspects of interpretation that refer to the patient's past, and link the unconscious aspects of the present with the unconscious aspects of the past.

Transference may be defined as the unconscious repetition in the here and now of pathogenic conflicts from the past, and the analysis of transference is the main source of specific change brought about by psychoanalytic treatment.

The classical concept of transference analysis has been expanded significantly by the concept of the analysis of the “total transference” proposed by the Kleinian approach1. This involves a systematic analysis of the transference implications of the patient's total verbal and nonverbal manifestations in the hours as well as the patient's direct and implicit communicative efforts to influence the analyst in a certain direction, and the consistent exploration of the transference implications of material from the patient's external life that, at any point, he/she brings into the session.

The inclusion of a systematic consideration of the patient's total functioning at the point of the activation of a predominant transference points to an important implicit consequence of transference interpretation, i.e., the analysis of character. Defensive characterological patterns tend to become dominant transference resistances and lend themselves to systematic analysis leading to characterological modification. This is a significant effect of psychoanalytic treatment, surprisingly underemphasized in the literature.

Technical neutrality tends to be misinterpreted as a recommendation for an analyst's distant, uninvolved attitude, “a mirror to the patient's presentations”. In essence, it simply refers to the analyst's not taking sides in the patient's activated internal conflicts, remaining equidistant, as A. Freud2 put it, from the patient's id, ego, and super ego, and from his/her external reality. Technical neutrality, in addition, implies the analyst's not attempting to influence the patient with his/her own value systems. S. Freud's early metaphor of the analyst as a “mirror” clearly was questioned by himself, and he protested against a view of analytic objectivity as “disgruntled indifference”3.

Technical neutrality also implies the concept of “abstinence”, in the sense that the analytic relationship should not be utilized for the gratification of libidinal or aggressive impulses of the patient or the analyst. In contrast, technical neutrality does not imply the concept of “anonymity”, a questionable development in psychoanalytic thinking in the 1950s, importantly related, in my view, to authoritarian pressures within psychoanalytic education, and the related institutionally fostered idealization of the training analyst, who should not show any usual personal human characteristic to the patient. This idealization of the analyst has been sharply criticized in recent years, particularly by the relational school.

Technical neutrality implies a natural and sincere approach to the patient within general socially appropriate behavior, as part of which the analyst avoids all references or focus upon his/her own life interests or problems. The analyst cannot avoid that personal features emerge in the treatment situation, and do become the source of transference reactions. The patient's realistic reaction to realistic aspects of the analyst's behavior should not be considered a transference reaction: not everything is transference! Maintaining the definition of transference as an inappropriate reaction to the reality presented by the analyst, that reflects the activation of the patient's unconscious conflicts, should differentiate transference from other patient's realistic reactions to natural, as well as idiosyncratic, aspects of the treatment situation.

Countertransference is the analyst's total, moment‐to‐moment emotional reaction to the patient and to the particular material that the patient presents. The contemporary view of countertransference is that of a complex formation co‐determined by the analyst's reaction to the patient's transference, to the reality of the patient's life, to the reality of the analyst's life, and to specific transference dispositions activated in the analyst as a reaction to the patient and his/her material.

Under ordinary circumstances, countertransference mostly is determined by the vicissitudes of the transference, and as such, the analyst's emotional reactions may fluctuate significantly within each session. In contrast to acute fluctuations of the countertransference, chronic distortions of the analyst's internal attitude toward the patient usually indicate significant difficulties in the analyst's understanding of the transference. They often point to a stalemate in the analytic situation that the analyst may need to resolve outside the actual times of analytic sessions with the patient, through self‐exploration or consultation. Serious characterological difficulties of the analyst may contribute to such chronic countertransference distortions, but most frequently they relate to more limited difficulties in his/her understanding and interpretations and are related to particular developments in the transference4.

Full internal tolerance of countertransference reactions, including regressive fantasies about specific relations with the patient, may be followed by the analyst's internal exploration of the meanings of his/her reaction in terms of the present transference situation, and thus prepare the road for transference analysis.

This is an overall outline of the basic aspects that, I suggest, essentially define psychoanalytic technique, and that may be applied to the analysis of various developments in the analytic situation, such as the analysis of dreams, character, acting out, and repetition compulsion, all of which, in the end, will culminate in transference analysis.

Otto F. Kernberg Personality Disorders Institute, New York Presbyterian Hospital, Westchester Division, and Weill Medical College of Cornell University, New York, NY, USA

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