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Chapter 28: Psychotherapies
Table 28.1-1
Scope of Psychoanalytic Practice: A Clinical Continuum
a
Psychoanalytic Psychotherapy
Feature
Psychoanalysis
Expressive Mode
Supportive Mode
Frequency
Regular four to five times per
week; “50-minute hour”
Regular one to three times per week;
half to full hour
Flexible one time per wk or less; or
as needed half to full hour
Duration
Long-term; usually 3 to 5
+
years Short or long term; several sessions to
months or years
Short or intermittent long term;
single session to lifetime
Setting
Patient primarily on couch with
analyst out of view
Patient and therapist face to face;
occasional use of couch
Patient and therapist face to face;
couch contraindicated
Modus
operandi
Systematic analysis of all
positive and negative
transference and resistance;
primary focus on analyst
and intrasession events;
transference neurosis
facilitated; regression
encouraged
Partial analysis of dynamics and
defenses; focus on current
interpersonal events and transference
to others outside of sessions; analysis
of negative transference; positive
transference left unexplored unless
impedes progress; limited regression
encouraged
Formation of therapeutic alliance
and real object relationship;
analysis of transference
contraindicated with rare
exceptions; focus on conscious
external events; regression
discouraged
Analyst/
therapist role
Absolute neutrality; frustration
of patient; reflector/mirror
role
Modified neutrality; implicit gratification
of patient and greater activity
Neutrality suspended; limited
explicit gratification, direction,
and disclosure
Mutative
change
agents
Insight predominates
within relatively deprived
environment
Insight within more empathic
environment; identification with
benevolent object
Auxiliary or surrogate ego as
temporary substitute; holding
environment; insight to degree
possible
Patient
population
Neuroses; mild character
psychopathology
Neuroses; mild to moderate character
psychopathology, especially
narcissistic and borderline disorders
Severe character disorders, latent or
manifest psychoses, acute crises,
physical illness
Patient
requisites
High motivation, psychological
mindedness; good previous
object relationships; ability
to maintain transference
neurosis; good frustration
tolerance
Moderate to high motivation and
psychological mindedness; ability
to form therapeutic alliance; some
frustration tolerance
Some degree of motivation and
ability to form therapeutic
alliance
Basic goals
Structural reorganization of
personality; resolution of
unconscious conflicts; insight
into intrapsychic events;
symptom relief an indirect
result
Partial reorganization of personality and
defenses; resolution of preconscious
and conscious derivatives of conflicts;
insight into current interpersonal
events; improved object relations;
symptom relief a goal or prelude to
further exploration
Reintegration of self and ability to
cope; stabilization or restoration
of preexisting equilibrium;
strengthening of defenses; better
adjustment or acceptance of
pathology; symptom relief and
environmental restructuring as
primary goals
Major
techniques
Free association method
predominates; full dynamic
interpretation (including
confrontation, clarification,
and working through),
with emphasis on genetic
reconstruction
Limited free association; confrontation,
clarification, and partial interpretation
predominate, with emphasis on here-
and-now interpretation and limited
genetic interpretation
Free association method
contraindicated; suggestion
(advise) predominates;
abreaction useful; confrontation,
clarification, and interpretation
in the here-and-now secondary;
genetic interpretation
contraindicated
Adjunct
treatment
Primarily avoided; if applied,
all negative and positive
meanings and implications
are thoroughly analyzed
May be necessary (e.g., psychotropic
drugs as temporary measure); if
applied, its negative implications
explored and diffused
Often necessary (e.g., psychotropic
drugs, family rehabilitative
therapy, or hospitalization); if
applied, its positive implications
are emphasized
a
This division is not categorical; all practice resides on a clinical continuum.
60s or 70s. One final contraindication is a close relationship with
the analyst. Analysts should avoid analyzing friends, relatives, or
persons with whom they have other involvements.
Patient Requisites
The most important patient requisites for psychoanalysis are
listed in Table 28.1-3.
Ms. M, a 29-year-old unmarried woman who worked in a low-
level capacity for a magazine, presented for consultation with the
chief complaints of considerable sadness and distress over her
parent’s reaction when they found that she had had a homosexual
relationship. She also realized that she had been working far below
her potential. She had never sought any treatment before. She was
clearly intelligent, sensitive, self-reflective, and insightful. When
