Psychoanalysis today

Topic: Connecting minds

In the 19th century and at the turn of the 20th century our understandings of the human mind and the clinical potentialities took a leap. Since then, we have gained variety of new insights through clinical experience, speculation, case studies, debates, and research into mental health and mental disorders. Where does psychoanalytical treatment fit in the clinical spectrum of contemporary psychology and psychiatry?

I wrote this at a coffee shop. Next to me sat two young psychologists so I asked what they would like to know about psychoanalysis. They said: How are psychoanalysts are trained? How is success measured? What interventions are used? How are interventions chosen? These big questions I will here only speculatively address from my personal perspective as a psychoanalyst: Psychoanalysts are trained in developmental psychology and of the current knowledge frontier regarding the cause, development, and cure of psychological and mental indisturbances. They are trained to use the therapeutic toolbox of psychodynamic treatments and in creating, maintaining, and making use of the analytical situation as a curative endeavour. The success of psychoanalytical treatment, if to be measured, is measured like the success of other psychological treatments, and against a set of clear set of success criteria. Psychoanalysts have a variety of treatment interventions at their disposal (See, for instance, Psychodynamic Intervention Rating Scale (PIRS), Modified Multidimensional Classification of Psychotherapeutic Interventions (CMIP-M) and Metatheoretical List of Therapeutic Interventions (MULTI)). Prudent psychoanalytical treatment is an enlightened improvisation where the analyst responds to the client with integrity and on strict moral ground, with both general and specific techniques, as to assess variations of the known and unknown psychological realties and dynamics that undermine the client´s health. In my mind, psychoanalysis proper has at its disposal a variety of clinical intervention that are unique, and will not easily be superseded.

Figure 1. Psychoanalystic interventions in clinical context.

Figure 1. Psychoanalystic interventions in clinical context.

Psychoanalysis is a process that entails a detailed — usually a one-on-one — examination of the complex phenomena that is human subjectivity and its implications on cognition, behaviour, affect, and outlook on life. Here, I will describe the initiation into psychoanalytical treatment as a progression (Figure 1): (A) Assessment, existential consideration (Known Knowns). In the initial assessment, the analyst can use variety of rapport building methods, diagnostic tools, coaching and positive encouragement. Initially the analyst explores what night be going in a non-structured, semi-structured, or diagnostically structured interview, depending on the mental state of the patient, motive, and the urgency of the situation. In serious cases the analyst refers the client to a mental clinic that has resources to manage the severity of the situation. The analyst is also committed to make appropriate referrals if they are more fitted. Here the analyst also aims to establish a therapeutic alliance. (B) Behavioural considerations (Unknown Knowns) where focus is on manifested maladaptive behaviour and the analyst can deploy variety of behavioural modification techniques. (C) Cognitive considerations (Known Unknowns) where the analyst explores cognitive schema and challenges irrational beliefs through variety of interventions.

If the schematic methods of A+B+C are not viable treatment options, the plough needs to be lowered and the cavernous treatment interventions of psychoanalysis considered (D). (D) Depth psychoanalytical considerations (unknown unknowns), in other words, psychoanalysis proper. Psychoanalysis aims at gently unmasking troubling mental aspects that the client tries to mask with behaviours, cognitive means, defence mechanisms, and/or character traits. The analyst tries to maintain compassionate analytic neutrality as not to take part in internal struggles of the patient. Even though the treatment can be regressive (revisiting the psychological past) the focus is always on the present. Interventions can, for instance, be exploratory (free association, anamnesis, biographical exploration), empathic (anticipation, repetition, synthesis, phatic order, acquiescence, and support), explanatory interventions (explanation and meta-intervention) and interpretation proper. The last, that aims at sparking a shift, can be dynamic (links defence to an affect), genetic (impact of past event on the present), an interpretation of resistance (avoiding of problems and therapeutic engagement), transference (old conflicts in current relationships, including with the analyst) and interpretation of fantasies and dreams (relevance for current situation). Indicative interventions can be in the form of suggestion or advice, instructions, examination, and confrontation. Then there are interventions involving people outside the analytical dyad, as well as play, sand-tray, drama, and art therapy. In case of low ego functioning more supportive approach might be used. Object-relational interventions are used with clients who have issues with early childhood deprivation, bonding, and attachment. With creative people one might lean more towards analytical psychoanalysis with a focus on active imagination, dream analysis, symbolic amplification, and archetypical dynamics. With clients with malfunctioning personalities, one might lean towards self-psychological interventions, with strong emphasis on empathy, understanding, and explaining. In all cases the client is encouraged to excavate the past as to alter the future and pursue personal integration in the here-and-now of the analytical situation, and then extent that integrity into the wider community. The outcome of psychoanalytical treatment ranges from turning hysterical misery into common unhappiness to total psychological rejuvenation and deeper appreciation of self and others. □