Change after long-term psychoanalytic psychotherapy

Psychoanalytic psychotherapy in clinical practice is traditionally a long-term treatment conducted by well-trained psychotherapists. However, very few studies have been published that evaluate the effects of such treatment. To redress this lack of studies, 55 individuals selected for long-term psychoanalytic psychotherapy (average, 3 years) were invited to participate in a naturalistic study. The psychotherapists had a mean of 15 years of professional experience. The 36 patients who completed psychotherapy manifested a substantial reduction in symptomatic suffering and decreased levels of character pathology, as measured by the Karolinska Psychodynamic Profile (KAPP) and the Karolinska Scales of Personality. Generally, such changes were not found in the individuals who did not engage in treatment. In the therapy group, improvements were found on eight KAPP subscales defining different aspects of character: Intimacy and Reciprocity, Frustration Tolerance, Regression in the Service of the Ego, Coping with Aggressive Affects, Conceptions of Bodily Appearance and their Significance for Self-esteem, Sexual Function, Sexual Satisfaction, and Personality Organization. The results indicate that individuals who engaged in psychotherapy improved their capacity to handle crucial aspects of life and reduced their symptomatic suffering.     

Audit in psychoanalytic psychotherapy with children and adolescents

The importance of multidisciplinary audit in child and adolescent psychiatry, including the work of child psychotherapists, is discussed. Research is highlighted which shows that certain groups of children in particular benefit from psychoanalytic psychotherapy. The problems related to auditing psychoanalytic psychotherapy are discussed, and a possible method of audit based on peer review of notes, which takes into account both inner and outer change, is presented.

A patient is discussed whose notes have been audited using the audit form. It is suggested that this form of audit has good educational potential as well as ensuring a high standard of patient care.     

Concurrent individual and individual-in-a-group psychoanalytic psychotherapy

This paper's thesis is that concurrent individual-in-a-group and individual psychoanalytic psychotherapy can be conducted in conformance with psychoanalytic principles of treatment as well as can individual psychoanalytic psychotherapy alone. American psychoanalysts have shown little interest in group psychotherapy, probably because of earlier criticism that transference is diluted by the greater reality of the therapist in group psychotherapy. This is a misconception extrapolated from the mirror model of dyadic analytic technique. The criticism was formulated during a period when that model was prominent and there was little awareness that the actual personal relationship between patient and analyst played an important facilitating role in the dyadic analytic process, including providing a basis for investiture of transference. Also, the criticism was based on one-session-per-week group psychotherapy, whereas concurrent individual-in-a-group and individual psychoanalytic psychotherapy utilizes two group sessions plus one or two individual sessions per week, enabling a more intensive patient-therapist relationship. Concurrent group and individual psychoanalytic psychotherapy constitutes a contribution to the widening scope of application of psychoanalytic treatment.     

Lines of advance in psychoanalytic psychotherapy

Freud's 1919 paper is taken as a starting-point to review how far we have advanced towards fulfilment of his prophetic remarks about the need to develop psychoanalytic psychotherapy for the masses. A glance is taken back to some of the circumstances and characters involved in Budapest where the paper was given at the 1918 congress, where there was much talk about the need to do something about the war neuroses. Similar pressures led to the founding of the Tavistock Clinic and Cassel Hospital in the UK, long before the start of the NHS. The pressures of both world wars advanced the applications of psychoanalysis; the next wave of pressures may come from NHS changes and entry into Europe. The history of psychoanalytic psychotherapy in the UK is also considered via looking briefly at the history and development of psychoanalytic publications, of the Tavistock Clinic, of psychoanalytic training, of child psychotherapy and the emergence of adult (non-medical) psychotherapy. There have always been tensions between exponents of the pure gold of analysis and the needs of its wider applications. More flexible arrangements and boundaries are necessary if we are to spread psychoanalysis beyond London and to fulfil Freud's own hopes about the large-scale application of psychoanalytic therapy.     

The symbolic and concrete: Psychotic adolescents in psychoanalytic psychotherapy

Unique disturbances in symbolisation are characteristic of the pathology of schizophrenia. Drawing on the case vignette of a psychotic adolescent, the author discusses theoretical problems in the symbolisation process in general and then in psychosis, in particular the relation between 'concretism' as a thought disorder and other psychotic defences. The ability to symbolise on the one hand and to maintain sufficiently stable ego boundaries on the other hand are examined in their relation. The author's clinical experience supports her hypothesis that there is a close relationship between the impairment of the symbolisation process in the adolescent or adult psychotic patient and his/her inability to engage in symbolic play as a child. Special attention is paid to the role of early trauma and consequent pathology of object relations for disturbances of symbolic play in childhood. Regression to concrete thinking is understood as the chance of the psychotic patient to give some meaning to reality in an unreal, delusional world and as his/her last chance to communicate at all. Conclusions are drawn for psychoanalytic techniques in the treatment of patients who are deeply regressed in this respect. Special attention is given to the particular circumstances and challenges of adolescence and to providing psychoanalytic psychotherapy to adolescent psychotic patients.     

Six things worth understanding about psychoanalytic psychotherapy

This paper is written for family therapists who may be curious but sceptical about psychoanalysis and psychoanalytic psychotherapy. It examines a number of areas of misunderstanding within mainstream family therapy discourse (diversity, authoritarianism, terminology, blame, history and separation) which, the author believes, have acted to help maintain a false coherence for family therapy through a distorted construction of the otherness of psychoanalytic therapy and, in so doing, inhibited a potentially more productive relationship.     

Acting,feeling and thinking: psychoanalytic psychotherapy with Tracey

This paper consists of a case study and commentary which formed a part of the inaugural lecture in a series entitled ‘Working with Psychosomatic Issues’*. The audience consisted of psychoanalytic, body psychotherapy and integrative practitioners. The presentation was divided into three parts, (1) an outline of philosophical themes that inform perspectives on health, illness and psychosomatic phenomena, (2) the case study reproduced below and (3) a summary of Winnicott's work (1960, 1966, 1988) on ‘the indwelling of the psyche in the soma’. The case study describes work with a young woman who harms herself through self-hitting and, in addition, expresses other physical manifestations of psychological distress. The core approach of the practitioner is psychoanalytic. The work is informed also by postmodern sensibilities and phenomenological themes.     

Dream frequency in psychoanalysis and psychoanalytic psychotherapy

The authors examine data on dream frequency from 50 patients, half of whom were seen in psychoanalysis and half in psychoanalytic psychotherapy. Frequency, defined as the proportion of sessions where at least one dream is related, is analyzed statistically as a function of sex, age, and type of treatment. Also, treatment outcome is examined as a function of sex, type of treatment, diagnosis, and dream frequency. Psychoanalytic patients are found to have higher dream frequency than the patients in the psychotherapy group. Higher average dream frequency is correlated with a better treatment outcome in both patient groups.     

Evaluation of psychoanalytic psychotherapy with children: Therapists' assessments and predictions

Meaningful and clinically relevant evaluation of psychoanalytical psychotherapy requires new models for research. Such evaluation needs to take account of the complexities of personality and innerworld change as well as the more simply assessed changes in external behaviour.

A pilot study to develop a suitable methodology is described. These preliminary results are on a consecutive series of twenty in care and adopted children entering psychotherapy at the Tavistock Clinic. The project evolved from a previous study of psychotherapy with severely deprived children (Boston & Szur 1983), but the method could be used with any group of children in psychoanalytic psychotherapy, and possibly also, in an adapted form, with adults.

Therapists' initial aims and predictions are compared with later assessments of both external, and a wide range of internal, changes. Methods of validation are discussed and case-illustrations given.     

On the nature and standing of psychoanalytic psychotherapy

In this paper, I offer some reflections on the standing of psychoanalytic psychotherapy in the National Health Service (NHS), with special reference to contemporary forms of evidence-based thinking. I consider what may follow when a narrow view of science or psychotherapeutic practice becomes conventional wisdom and assumes dominance. I place stress on the potential loss to NHS psychology and psychiatry if psychoanalytic psychotherapy becomes increasingly marginalized on the one hand, or overly standardized on the other.     

Therapeutic technique in psychoanalysis and psychoanalytic psychotherapy.

As the distinctions between what we consider to be psychoanalysis and what we consider to be psychoanalytic psychotherapy have become more uncertain and more blurred, it follows that it is equally difficult to designate the techniques that would be appropriate and specific for each modality. The problem has been compounded by the fact that in recent years psychoanalysis in the United States has become considerably less homogeneous than in the past and the ego-psychological structural model is no longer the only point of view in the psychoanalytic marketplace. Further, with alterations in the criteria for analyzability, cases which, generally, had not been viewed as suitable for analysis, have been appearing with increasing frequency on psychoanalysts' couches. We have also recognized that the degree of congruence between our expectations from and the results of psychoanalytic treatment was often less than anticipated. It appears that analysts have become considerably less arbitrary about what psychoanalysis is and how a psychoanalysis can be carried out. The author is unable to delineate one technique that is intrinsic to and limited to psychoanalysis. There are, however, differences in degree and emphasis in the ways in which various techniques are applied in the therapy of psychoanalysis as compared to the therapy of psychoanalytic psychotherapy. Special attention is given to the role of a psychoanalytic process and the central place the analysis of resistance plays in psychoanalytic therapy.