Analytic psychotherapy has changed and developed since the time of Freud, with increasing emphasis on the therapeutic relationship. A recent survey of my former patients — seen over a period spanning five decades — highlights 9 particular ingredients that help place the relationship at the heart of successful therapy.
From Freud’s time, and for many years thereafter, psychoanalysis and psychoanalytic psychotherapy have been pictured with a patient lying on a couch, with the analyst — usually bearded — sitting behind taking notes. In the public mind, being ‘analyzed’ means having your personality and actions interpreted, and being told what your motives and acts ‘really’ mean, by a wise analyst who knows your unconscious better than you do.
In many fields, when basic ideas change, such changes percolate down to the general population. But this has happened very little with psychoanalytic psychotherapy. It is a shame, for the old version of psychoanalysis is dying out; it is confined to an increasingly small number of aging analysts. In its place is an interrelated set of new approaches that go by different names: psychodynamic psychotherapy, self-psychology (associated with Heinz Kohut and his followers), the relational approach (Philip Bromberg’s work is a fine example), intersubjectivity (see Stolorow, Brandchaft and Atwood), the interpersonal school (a later development of the work of the Neo-Freudian Harry Stack Sullivan), and others. While there are differences between these various approaches, the similarities out-weigh them. In addition to these contemporary versions of analytic psychotherapy, a great deal of research supports these modern approaches (see Shedler, 2010, for a summary.)
The general reader, as well as anyone seeking therapy for their psychological difficulties — be these anxiety, depression, relationship problems, addictions, and the like — should be aware that there are new forms of analytic therapy which can be extremely helpful. Let me add just one caveat here. There has been a long tradition for the field to be divided into ‘schools’ or ‘movements’ associated with a revered leader. Thus, there are ‘Freudians’, ‘Jungians’, ‘Adlerians’, ‘Kleinians,’ and, more recently, ‘Kohutians’. I think this has been unfortunate, and has few parallels in medicine or other scientific fields. What I think would have been preferable, and what has been happening more in recent years, is to take the best ideas and methods — those that have been proven helpful both in clinical work and research — from all these schools, and other sources, and use what is most effective for each individual patient.
What are the components of contemporary analytic psychotherapy? Here I will draw on my recent book, Psychotherapy: Lives Intersecting [Amazon-US | Amazon-UK]. I conducted an informal survey of more than thirty patients whom I had seen over the last fifty years, asking them to describe, in their own words, what they found most helpful, curative, or therapeutic in our work together, and also what was not helpful. Since, for a number of them, the therapy had ended more than twenty years earlier, the study is also a long-term follow-up, in which we can see if the gains they had made lasted, expanded or regressed. Such a follow-up is relatively rare in the literature, as is a study in which the outcome is primarily described by the patient rather than the therapist.
As one reviewer of the book put it, “the relationship rules.” The most striking finding of the survey was that relationship factors were far and away most commonly described as the key ingredients in successful treatment, for example:
- a therapist who listens closely in a non-judgmental manner;
- empathy — attempting to see things from the patient’s point of view;
- catharsis, or the open expression of a range of emotions;
- friendliness, as contrasted to the traditional psychoanalytic stance of ‘neutrality’ and ‘abstinence;’
- flexibility with fees;
- interpretations that were individually crafted to each unique person, as opposed to those taken from one theory or another;
- admitting and repairing mistakes;
When I acted in these ways, the patients reported lasting changes in their conceptions of themselves — increased self-esteem and self-acceptance; changes in their patterns of relating to others; and marked reductions in anxiety, depression and other painful emotional states. These changes lasted and, in some cases, expanded over the years. I will cite just a few examples here.
A depressed woman, after a number of years of analysis, said, “I no longer hated myself. I only got to like myself because I finally felt that you liked me.” Another young woman said, “Throughout my therapy experience with you, I always felt like a person in a relationship, rather than a specimen to be understood by you, and then explained back to me. You treated my own assessments and insights with respect. My sense was that you were looking to me to tell you about myself, and that we would work together to figure things out.” Others spoke of the liberating effect of “blowing off steam” — being able to fully express emotions that had been pent up for years.
Insight into aspects of themselves that they were not aware of — the hallmark of traditional psychoanalytic approaches — was mentioned as important, but it was typically not as central as the relationship factors.
- Breger, L. (2012) Psychotherapy: Lives Intersecting. New Brunswick, NJ: Transaction Publishers. [Amazon-US | Amazon-UK]
- Bromberg, P. M. (2011) The Shadow of the Tsunami: And the Growth of the Relational Mind. New York, NY: Routledge. [Amazon-US | Amazon-UK]
- Kohut, H. (1977) The Restoration of the Self. New York, NY: International Universities Press. [Amazon-US | Amazon-UK]
- Shedler, J. (2010) ‘The Efficacy of Psychodynamic Psychotherapy’, American Psychologist 65: 98-109.
- Stolorow, R. D., B. Brandchaft, and G. E. Atwood (2000) Psychoanalytic Treatment: An Intersubjective Approach. Hillsdale, NJ: Analytic Press. [Amazon-US | Amazon-UK]
- Sullivan, H. S. (1953) The Interpersonal Theory of Psychiatry. New York and London: W. W. Norton. [Amazon-US | Amazon-UK]