To paraphrase Mark Twain, the demise of psychoanalysis has been greatly exaggerated. I am an early-career psychiatrist, trained in a mainstream residency, and I prescribe medication to the majority of my patients. Yet, about 10% of my practice is psychoanalytic—and I believe that these patients are benefiting tremendously from this very intensive type of therapy.
In this article, I’ll discuss the current status of psychoanalysis, some of the evidence for its efficacy, and why I’ve found it so useful for my patients.
A brief description
Psychoanalysis was developed by Sigmund Freud and colleagues in Vienna in the 1890s. As practiced today, psychoanalytic technique focuses on the unconscious basis of feelings and behaviors. The main theory is that emotional distress and dysfunctional behavior are often caused by unconscious feelings and memories that patients try to suppress, especially those that involve internal conflict. These feelings leak out in various ways, despite psychological defense mechanisms patients use to prevent this.
Psychodynamic therapy and psychoanalysis are similar. Both ascribe to the above theory of the mind, but a psychodynamic therapist will typically meet with a patient 1–2 times per week, sit face to face, and converse with the patient. A psychoanalyst will meet with the patient more frequently (3–5 times a week) and for a longer time period (4–5 years). The patient lies on a couch and “free associates,” saying whatever comes to mind, including fantasies, dreams, and thoughts about the analyst, while the analyst sits out of view behind the couch, primarily listening, but occasionally interpreting the patient’s comments.
Theoretically, psychoanalysis works by altering self-defeating patterns, and it does so by helping patients get to know their own minds, especially the unconscious processes that produce difficulties in relationships and work.
The analyst finds clues to these unconscious feelings by listening for links between a patient’s associations; noting slips of the tongue; interpreting dreams; using the associations and countertransference reactions in the analyst’s own mind; and focusing on the transference, meaning the reenacting of a past relationship in the context of the therapy session.
Over time, the analyst presents all this data to the patient in the form of comments, or “interpretations.” If all goes well, the complicating patterns of the patient’s life come to light, and the patient is able to alter them. This process often requires the patient to mourn the loss of familiar ways of interacting with the world, and to replace rigid thinking and a harsh self-image with a gentler perspective, modeled by the analyst.
Psychoanalysis today: Who practices it, and what’s the evidence?
Psychoanalysis is widely practiced by psychiatrists, psychologists, and social workers. There are 3,500 active members of the American Psychoanalytic Association (APSaA), 65% of whom are psychiatrists, and there are many more practicing analysts who were trained by U.S. institutes not affiliated with APSaA.
Like any psychotherapy, the effectiveness of psychoanalysis is not easy to evaluate. This is largely because randomized clinical trials (RCTs) require a control group with which to compare the active treatment. In drug trials, you can assign some patients to the drug and others to a placebo sugar pill. In therapy trials, finding a believable placebo condition is much more challenging than in medication trials. This is especially true of psychoanalysis, because the treatment is more intensive and longer lasting than other psychotherapies.
The most recent meta-analysis of psychoanalytic research looked at 14 studies, which enrolled a total of 603 patients, with the number of patients in each study varying from 17 to 92. Psychoanalysis was defined as at least 2 sessions per week, with the patient lying on the couch. In these studies, the duration of analysis ranged from 2.5 to 6.5 years. Only one of these studies was an RCT that included a control group. The other 13 were pre/post cohort studies, meaning that all patients were assigned to the same treatment (psychoanalysis) and researchers compared their symptoms before treatment with symptoms after treatment.
In terms of results, the good news for psychoanalysis was that the overall effect size was 1.27, which indicates robust symptom improvement. The bad news was that the methodology of these studies was variable, limiting confidence in the results. Different studies enrolled different diagnoses, different symptom measurements were used, and, as mentioned, there was only one study that met the gold standard of randomizing patients to a control group (De Maat S et al, Harv Rev Psychiatry 2013;21(3):107– 137).
While there is much work to be done in proving the merits of psychoanalysis, at least we can say that these studies are consistent with the notion that this classical treatment—couch, silent doctor, and all—might be effective. And that certainly mirrors my own clinical experience.
During my psychiatric residency, I quickly realized that the more deeply I understood my patients, the more I could help them, and the more interesting the work was to me.