Editing Psychoanalysis (section)

==Treatment==
{{More citations needed section|date=May 2020}}
Using the various analytic and psychological techniques to [[Psychological Evaluation|assess]] mental problems, some believe{{by whom|date=July 2021}} that there are particular constellations of problems that are especially suited for analytic treatment (see below) whereas other problems might respond better to medicines and other interpersonal interventions.<ref name="INSERM" /> To be treated with psychoanalysis, whatever the presenting problem, the person requesting help must demonstrate a desire to start an analysis. The person wishing to start an analysis must have some capacity for speech and communication. As well, they need to be able to have or develop trust and insight within the psychoanalytic session. Potential patients must undergo a preliminary stage of treatment to assess their amenability to psychoanalysis at that time, and also to enable the analyst to form a working psychological model, which the analyst will use to direct the treatment. Psychoanalysts mainly work with neurosis and hysteria in particular; however, adapted forms of psychoanalysis are used in working with schizophrenia and other forms of psychosis or mental disorder. Finally, if a prospective patient is severely suicidal, a longer preliminary stage may be employed, sometimes with sessions which have a twenty-minute break in the middle. There are numerous modifications in technique under the heading of psychoanalysis due to the individualistic nature of personality in both analyst and patient.

The most common problems treatable with psychoanalysis include: [[phobia]]s, [[Conversion syndrome|conversions]], [[Compulsive behavior|compulsions]], [[Fixation (psychology)|obsessions]], [[anxiety attacks]], [[depression (mood)|depressions]], [[sexual dysfunction]]s, a wide variety of relationship problems (such as dating and marital strife), and a wide variety of character problems (for example, painful shyness, meanness, obnoxiousness, workaholism, hyperseductiveness, hyperemotionality, hyperfastidiousness). The fact that many of such patients also demonstrate deficits above makes diagnosis and treatment selection difficult.

Analytical organizations such as the IPA, APsaA and the European Federation for Psychoanalytic Psychotherapy have established procedures and models for the indication and practice of psychoanalytical therapy for trainees in analysis. The match between the analyst and the patient can be viewed as another contributing factor for the indication and contraindication for psychoanalytic treatment. The analyst decides whether the patient is suitable for psychoanalysis. This decision made by the analyst, besides being made on the usual indications and pathology, is also based to a certain degree on the "fit" between analyst and patient. A person's suitability for analysis at any particular time is based on their desire to know something about where their illness has come from. Someone who is not suitable for analysis expresses no desire to know more about the root causes of their illness.

An evaluation may include one or more other analysts' independent opinions and will include discussion of the patient's financial situation and insurance.

===Techniques===
The foundation of psychoanalysis is an interpretation of the patient's unconscious conflicts that are interfering with current-day functioning – conflicts that are causing painful symptoms such as phobias, anxiety, depression, and compulsions. [[James Strachey|Strachey]] (1936) stressed that figuring out ways the patient distorted perceptions about the analyst led to understanding what may have been forgotten.<ref group="lower-roman">also see Freud's paper "Repeating, Remembering, and Working Through"</ref> In particular, unconscious hostile feelings toward the analyst could be found in symbolic, negative reactions to what [[Robert Langs]] later called the "frame" of the therapy<ref>[[Robert Langs|Langs, Robert]]. 1998. ''Ground Rules in Psychotherapy and Counselling''. London: Karnac.</ref>—the setup that included times of the sessions, payment of fees, and the necessity of talking. In patients who made mistakes, forgot, or showed other peculiarities regarding time, fees, and talking, the analyst can usually find various unconscious "resistances" to the flow of thoughts (aka [[free association (psychology)|free association]]).

When the patient reclines on a couch with the analyst out of view, the patient tends to remember more experiences, more resistance and transference, and is able to reorganize thoughts after the development of insight through the interpretive work of the analyst. Although fantasy life can be understood through the examination of [[dream]]s, masturbation fantasies<ref group="lower-roman">[[cf.]] Marcus, I. and J. Francis. 1975. ''Masturbation from Infancy to Senescence''.</ref> are also important. The analyst is interested in how the patient reacts to and avoids such fantasies.<ref>Gray, Paul. 1994. ''The Ego and Analysis of Defense''. J. Aronson.</ref> Various memories of early life are generally distorted—what Freud called ''[[Screen Memories (Freud)|screen memories]]''—and in any case, very early experiences (before age two)—cannot be remembered.<ref group="lower-roman">see the child studies of Eleanor Galenson on "evocative memory"</ref>

====Variations in technique====
There is what is known among psychoanalysts as ''classical technique'', although Freud throughout his writings deviated from this considerably, depending on the problems of any given patient.

''Classical technique'' was summarized by Allan Compton as comprising:<ref>{{cite web |title=Psychoanalytic Techniques |url=https://psynso.com/psychoanalytic-techniques/ |publisher=Psynso |access-date=24 December 2022}}</ref>

* Instructions: telling the patient to try to say what's on their mind, including interferences;
* Exploration: asking questions; and
* Clarification: rephrasing and summarizing what the patient has been describing.

As well, the analyst can also use confrontation to bring an aspect of functioning, usually a defense, to the patient's attention. The analyst then uses a variety of interpretation methods, such as:

* Dynamic interpretation: explaining how being too nice guards against guilt (e.g. defense vs. affect);
* Genetic interpretation: explaining how a past event is influencing the present;
* Resistance interpretation: showing the patient how they are avoiding their problems;
* [[Transference]] interpretation: showing the patient ways old conflicts arise in current relationships, including that with the analyst; or
* Dream interpretation: obtaining the patient's thoughts about their dreams and connecting this with their current problems.

Analysts can also use reconstruction to estimate what may have happened in the past that created some current issue. These techniques are primarily based on [[Conflict theories|''conflict theory'']] (see above). As ''object relations theory'' evolved, supplemented by the work of [[John Bowlby]] and [[Mary Ainsworth]], techniques with patients who had more severe problems with basic trust ([[Erik Erikson|Erikson]], 1950) and a history of [[maternal deprivation]] (see the works of Augusta Alpert) led to new techniques with adults. These have sometimes been called interpersonal, intersubjective (cf. [[Robert Stolorow|Stolorow]]), relational, or corrective object relations techniques.

Ego psychological concepts of deficit in functioning led to refinements in supportive therapy. These techniques are particularly applicable to psychotic and near-psychotic (cf., Eric Marcus, "Psychosis and Near-psychosis") patients. These supportive therapy techniques include discussions of reality; encouragement to stay alive (including hospitalization); psychotropic medicines to relieve overwhelming depressive affect or overwhelming fantasies (hallucinations and delusions); and advice about the meanings of things (to counter abstraction failures).

The notion of the "silent analyst" has been criticized. Actually, the analyst listens using Arlow's approach as set out in "The Genesis of Interpretation", using active intervention to interpret resistances, defenses, creating pathology, and fantasies. Silence is not a technique of psychoanalysis (see also the studies and opinion papers of Owen Renik). "[[Neutrality (psychoanalysis)|Analytic neutrality]]" is a concept that does not mean the analyst is silent. It refers to the analyst's position of not taking sides in the internal struggles of the patient. For example, if a patient feels guilty, the analyst might explore what the patient has been doing or thinking that causes the guilt, but not reassure the patient not to feel guilty. The analyst might also explore the identifications with parents and others that led to the guilt.<ref>{{Cite journal |last=Leider |first=Robert J. |date=1983-01-01 |title=Analytic neutrality—a historical review |url=https://doi.org/10.1080/07351698309533520 |journal=Psychoanalytic Inquiry |volume=3 |issue=4 |pages=665–674 |doi=10.1080/07351698309533520 |issn=0735-1690|url-access=subscription }}</ref><ref>Greenberg, J. (1986) [https://www.wawhite.org/uploads/PDF/E1f_10%20Greenberg_J_Analytic_Neutrality.pdf The Problem of Analytic Neutrality] {{Webarchive|url=https://web.archive.org/web/20220608093724/https://www.wawhite.org/uploads/PDF/E1f_10%20Greenberg_J_Analytic_Neutrality.pdf |date=2022-06-08 }}. Contemp. Psychoanal., 22:76-86</ref>

Interpersonal–relational psychoanalysts emphasize the notion that it is impossible to be neutral. [[Harry Stack Sullivan|Sullivan]] introduced the term ''[[Participant observation|participant-observer]]'' to indicate the analyst inevitably interacts with the analysand, and suggested the detailed inquiry as an alternative to interpretation. The detailed inquiry involves noting where the analysand is leaving out important elements of an account and noting when the story is obfuscated, and asking careful questions to open up the dialogue.<ref>{{Cite journal |last=Green |first=Maurice R. |date=1977-07-01 |title=Sullivan's Participant Observation |url=https://doi.org/10.1080/00107530.1977.10745493 |journal=Contemporary Psychoanalysis |volume=13 |issue=3 |pages=358–360 |doi=10.1080/00107530.1977.10745493 |issn=0010-7530|url-access=subscription }}</ref>

===Group therapy and play therapy===
Although single-client sessions remain the norm, psychoanalytic theory has been used to develop other types of psychological treatment. Psychoanalytic group therapy was pioneered by [[Trigant Burrow]], Joseph Pratt, [[Paul Ferdinand Schilder|Paul F. Schilder]], [[Samuel Slavson|Samuel R. Slavson]], [[Harry Stack Sullivan]], and Wolfe. Child-centered counseling for parents was instituted early in analytic history by Freud, and was later further developed by [[Irwin Marcus]], Edith Schulhofer, and Gilbert Kliman. Psychoanalytically based couples therapy has been promulgated and explicated by Fred Sander. Techniques and tools developed in the first decade of the 21st century have made psychoanalysis available to patients who were not treatable by earlier techniques. This meant that the analytic situation was modified so that it would be more suitable and more likely to be helpful for these patients. Eagle (2007) believes that psychoanalysis cannot be a self-contained discipline but instead must be open to influence from and integration with findings and theory from other disciplines.<ref>Eagle, Morris N. 2007. "[https://semanticscholar.org/paper/2403e3b4cb03f1b54e1b8205053a010d3416aab6 Psychoanalysis and its critics]." ''[[Psychoanalytic Psychology (journal)|Psychoanalytic Psychology]]'' 24:10–24. {{doi|10.1037/0736-9735.24.1.10}}.</ref>

Psychoanalytic constructs have been adapted for use with children with treatments such as [[play therapy]], [[art therapy]], and [[storytelling]]. Throughout her career, from the 1920s through the 1970s, [[Anna Freud]] adapted psychoanalysis for children through play. This is still used today for children, especially those who are preadolescent.<ref group="lower-roman">see Leon Hoffman, New York Psychoanalytic Institute Center for Children</ref> Using toys and games, children are able to symbolically demonstrate their fears, fantasies, and defenses; although not identical, this technique, in children, is analogous to the aim of free association in adults. Psychoanalytic play therapy allows the child and analyst to understand children's conflicts, particularly defenses such as disobedience and withdrawal, that have been guarding against various unpleasant feelings and hostile wishes. In art therapy, the counselor may have a child draw a portrait and then tell a story about the portrait. The counselor watches for recurring themes—regardless of whether it is with art or toys.{{Citation needed|date=May 2020}}

===Cultural variations===
Psychoanalysis can be adapted to different [[cultures]], as long as the therapist or counselor understands the client's culture.<ref>{{cite journal |last1=Hall |first1=Gordon C. Nagayama |last2=Kim-Mozeleski |first2=Jin E. |last3=Zane |first3=Nolan W. |last4=Sato |first4=Hiroshi |last5=Huang |first5=Ellen R. |last6=Tuan |first6=Mia |last7=Ibaraki |first7=Alicia Y. |title=Cultural adaptations of psychotherapy: Therapists' applications of conceptual models with Asians and Asian Americans. |journal=Asian American Journal of Psychology |date=March 2019 |volume=10 |issue=1 |pages=68–78 |doi=10.1037/aap0000122 <!--|access-date=29 March 2023-->|pmid=30854159 |pmc=6402600 }}</ref> For example, Tori and Blimes found that defense mechanisms were valid in a normative sample of 2,624 [[Thai people|Thais]]. The use of certain defense mechanisms was related to cultural values. For example, Thais value calmness and collectiveness (because of [[Buddhism|Buddhist]] beliefs), so they were low on [[regressive emotionality]]. Psychoanalysis also applies because Freud used techniques that allowed him to get the subjective perceptions of his patients. He takes an objective approach by not facing his clients during his talk therapy sessions. He met with his patients wherever they were, such as when he used free association, where clients would say whatever came to mind without self-censorship. His treatments had little to no structure for most cultures, especially Asian cultures. Therefore, it is more likely that Freudian constructs will be used in structured therapy.<ref name="Thompson">Thompson, M. Guy. 2004. ''The Ethic of Honesty: The Fundamental Rule of Psychoanalysis''. [[Rodopi (publisher)|Rodopi]]. p. 75.</ref> In addition, Corey postulates that it will be necessary for a therapist to help clients develop a [[cultural identity]] as well as an ego identity.

===Psychodynamic therapy===
According to the NIH, psychodynamic therapy focuses on how an individual’s present behavior is affected by past experiences and the unconscious processes.<ref>{{Citation |last1=Opland |first1=Caitlin |title=Psychodynamic Therapy |date=2024 |work=StatPearls |url=https://www.ncbi.nlm.nih.gov/books/NBK606117/ |access-date=2024-11-09 |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=39163451 |last2=Torrico |first2=Tyler J.}}</ref> The main goal associated with psychodynamic therapy is internal reflection; for the patient to be able to understand more about their current behaviors after self-reflection and a critical analyzation of their past with their therapist. In order for this method of treatment to be effective, there must be a strong foundation of trust between the patient and their therapist. Often, psychodynamic therapy requires a large time investment, taking many years for considerable improvement and is not considered a quick solution.

===Cost and length of treatment===
The cost to the patient of psychoanalytic treatment ranges widely from place to place and between practitioners.<ref>{{Cite journal |last1=Berghout |first1=Caspar C. |last2=Zevalkink |first2=Jolien |last3=Roijen |first3=Leona Hakkaart-van |date=January 2010 |title=A cost-utility analysis of psychoanalysis versus psychoanalytic psychotherapy |url=https://www.cambridge.org/core/journals/international-journal-of-technology-assessment-in-health-care/article/abs/costutility-analysis-of-psychoanalysis-versus-psychoanalytic-psychotherapy/DEB6C109AAAE748C7295574C591F7046 |journal=International Journal of Technology Assessment in Health Care |language=en |volume=26 |issue=1 |pages=3–10 |doi=10.1017/S0266462309990791 |pmid=20059775 |s2cid=1941768 |issn=1471-6348|hdl=2066/90761 |hdl-access=free }}</ref> Low-fee analysis is often available in a psychoanalytic training clinic and graduate schools.<ref name="academic.oup.com">{{cite book | last=Sharpless | first=Brian A. | editor-first1=Brian A. | editor-last1=Sharpless | title=Psychodynamic Therapy Techniques | chapter=The Process of Interpretation | publisher=Oxford University Press | date=2019 | isbn=978-0-19-067627-8 | doi=10.1093/med-psych/9780190676278.003.0013 | pages=152–176}}</ref> Otherwise, the fee set by each analyst varies with the analyst's training and experience. Since, in most locations in the United States, unlike in Ontario and Germany, classical analysis (which usually requires sessions three to five times per week) is not covered by health insurance, many analysts may negotiate their fees with patients whom they feel they can help, but who have financial difficulties. The modifications of analysis, which include psychodynamic therapy, brief therapies, and certain types of group therapy,<ref group="lower-roman">cf. Slavson, S. R., ''A Textbook in Analytic Group Therapy''</ref> are carried out on a less frequent basis—usually once, twice, or three times a week – and usually the patient sits facing the therapist. As a result of the [[defense mechanism]]s and the lack of access to the unfathomable elements of the unconscious, psychoanalysis can be an expansive process that involves 2 to 5 sessions per week for several years. This type of therapy relies on the belief that reducing the symptoms will not actually help with the root causes or irrational drives. The analyst typically is a 'blank screen', disclosing very little about themselves in order that the client can use the space in the relationship to work on their unconscious without interference from outside.<ref name="Kernberg 287–288">{{Cite journal |last=Kernberg |first=Otto F. |date=October 2016 |title=The four basic components of psychoanalytic technique and derived psychoanalytic psychotherapies |journal=World Psychiatry |volume=15 |issue=3 |pages=287–288 |doi=10.1002/wps.20368 |issn=1723-8617 |pmc=5032492 |pmid=27717255}}</ref>

The psychoanalyst uses various methods to help the patient become more self-aware, insightful and uncover the meanings of symptoms. Firstly, the psychoanalyst attempts to develop a safe and confidential atmosphere where the patient can report feelings, thoughts and fantasies.<ref name="Kernberg 287–288" /> Analysands (as people in analysis are called) are asked to report whatever comes to mind without fear of reprisal. Freud called this the "fundamental rule". Analysands are asked to talk about their lives, including their early life, current life and hopes and aspirations for the future. They are encouraged to report their fantasies, "flash thoughts" and dreams. In fact, Freud believed that dreams were, "the royal road to the unconscious"; he devoted an entire volume to the interpretation of dreams. Freud had his patients lie on a couch in a dimly lit room and would sit out of sight, usually directly behind them, as to not influence the patient's thoughts by his gestures or expressions.<ref>{{cite book|last1=Hergenhahn|first1=Baldwin|title=An Introduction to Theories of Personality|last2=Olson|first2=Matthew|publisher=Pearson Prentice Hall|year=2007|isbn=978-0-13-194228-8|location=Upper Saddle River, New Jersey|pages=45–46}}</ref>

The psychoanalyst's task, in collaboration with the analysand, is to help deepen the analysand's understanding of those factors, outside of his awareness, that drive his behaviors. In the safe environment psychoanalysis offers, the analysand becomes attached to the analyst and pretty soon, he begins to experience the same conflicts with his analyst that he experiences with key figures in his life, such as his parents, his boss, his significant other, etc. It is the psychoanalyst's role to point out these conflicts and to interpret them. The transferring of these internal conflicts onto the analyst is called "[[transference]]".<ref name="Kernberg 287–288" />

Many studies have also been done on briefer "dynamic" treatments; these are more expedient to measure and shed light on the therapeutic process to some extent. Brief Relational Therapy (BRT), Brief Psychodynamic Therapy (BPT), and Time-Limited Dynamic Therapy (TLDP) limit treatment to 20–30 sessions. On average, classical analysis may last 5.7 years, but for phobias and depressions uncomplicated by ego deficits or object relations deficits, analysis may run for a shorter period of time.{{medical citation needed|date=September 2018}} Longer analyses are indicated for those with more serious disturbances in object relations, more symptoms, and more ingrained character pathology.<ref>{{Citation |last=Treatment |first=Center for Substance Abuse |title=Chapter 7—Brief Psychodynamic Therapy |date=1999 |url=https://www.ncbi.nlm.nih.gov/books/NBK64952/ |work=Brief Interventions and Brief Therapies for Substance Abuse |access-date=2023-12-06 |publisher=Substance Abuse and Mental Health Services Administration (US) |language=en}}</ref>