Psychoanalysis is a theory of human mental phenomena and behavior, a method of psychic investigation and research, and a form of psychotherapy originally formulated by Freud. As a method of treatment, it is the most intensive and rigorous of this type of psychotherapy. The patient is seen three to five times a week, generally for a minimum of several hundred hours over a number of years. The patient lies on a couch with the analyst seated behind, out of the patient’s visual range. The patient attempts to say freely and without censure whatever comes to mind, to associate freely, so as to follow as deeply as possible the train of thoughts to their earliest roots. As a technique for exploring the mental processes, psychoanalysis includes the use of free association and the analysis and interpretation of dreams, resistances, and transferences. The analyst uses interpretation and clarification to help the patient work through and resolve conflicts that have been affecting the patient’s life, often unconsciously. Psychoanalysis requires that the patient be stable, highly motivated, verbal, and psychologically minded. The patient also must be able to tolerate the stress generated by analysis without becoming overly regressed, distraught, or impulsive. As a form of psychotherapy, it uses the investigative technique, guided by Freud’s libido and instinct theories and by ego psychology, to gain insight into a person’s unconscious motivations, conflicts, and symbols and thus to effect a change in maladaptive behavior.

Based on the same principles and techniques as classic psychoanalysis, but less intense. There are two types: (1) insight-oriented or expressive psychotherapy and (2) supportive or relationship psychotherapy. Patients are seen one to two times a week and sit up facing the psychiatrist. The goal of resolution of unconscious psychological conflict is similar to that of psychoanalysis, but a greater emphasis is placed on day-to-day reality issues and a lesser emphasis on the development of transference issues. Patients suitable for psychoanalysis are suitable for this therapy, as are patients with a wider range of symptomatic and characterological problems. Patients with personality disorders are also suitable for this therapy. A comparison of psychoanalysis and psychoanalytically oriented psychotherapy is presented in Table 29-1.

In supportive psychotherapy, the essential element is support rather than the development of insight. This type of therapy often is the treatment of choice for patients with serious ego vulnerabilities, particularly psychotic patients. Patients in a crisis situation, such as


acute grief, are also suitable. This therapy can be continued on a long-term basis and last many years, especially in the case of patients with chronic problems. Support can take the form of limit setting, increasing reality testing, reassurance, advice, and help with developing social skills.

A short-term treatment, generally consisting of 10 to 40 sessions during a period of less than 1 year. The goal, based on psychodynamic theory, is to develop insight into underlying conflicts; such insight leads to psychological and behavioral changes.

This therapy is more confrontational than the other insight-oriented therapies in that the therapist is very active in repeatedly directing the patient’s associations and thoughts to conflictual areas. The number of hours is explicitly agreed on by the therapist and patient before the beginning of therapy, and a specific, circumscribed area of conflict is chosen to be the focus of treatment. More extensive change is not attempted. Patients suitable for this therapy must be able to define a specific central problem to be addressed and must be highly motivated, psychologically minded, and able to tolerate the temporary increase in anxiety or sadness that this type of therapy can evoke. Patients who are not suitable include those with fragile ego structures (e.g., suicidal or psychotic patients) and those with poor impulse control (e.g., borderline patients, substance abusers, and antisocial personalities).