towards understanding more about psychoanalytic psychotherapy  
 

Towards Understanding More About Psychoanalytic Psychotherapy

A Presentation in Five Parts

For health care and other professionals concerned with mental health. Based on a presentation made on 3rd February 1999 to the Continuing Medical Education programme for Oxford G.Ps. Those contributing are: Mr Lawrence Brown, Dr Jacqueline Ferguson, Dr Jean Knox, Mr Philip Roys and Ms Andrea Watson.

Part One - Setting the Scene
Part Two - What are the differences from counselling?
Part Three - What is transference?
Part Four - What happens during therapy; why is it necessary to attend sessions more than once a week and why does it take so long?
Part Five - Is there evidence based research as to its efficacy?

Part One - Setting the Scene

The purpose of this presentation is to inform you about psychoanalytic psychotherapy and to develop a dialogue out of which we hope greater understanding will emerge about the kinds of patients who require the investment of time and money necessary for psychoanalytic psychotherapy.

Psychoanalytic psychotherapy is a method of treatment for conditions sometimes presenting with physical symptoms and other times as disturbed states of mind. It makes use of the relationship between therapist and patient to rework (often through re-creating) significant past relationships and requires the active participation of both patient and therapist. It is thus demanding on both patient and therapist in allowing this recreation to take place over time. It develops its own pace often requiring patient and therapist to revisit the same ground over and over again. In an increasingly fast food culture, psychoanalytic psychotherapy is often criticised for the length of time it takes and apparent lack of specific goals.

The presentation avoids jargon - the exception to this is the word "transference" to which we shall return because of its importance in understanding this re-creation.

First, however, a word about psychotherapy, the British Confederation of Psychotherapist and the health professions.

The major health care professions have representatives on the Advisory Board of the BCP and a fellow of the Royal College of General Practitioners, Dr Andrew Elder, gave a keynote speech when the BCP's Register of Psychotherapists was launched. This was at the Royal College of General Practitioners in 1994. Dr Elder became the second Chairman of our Advisory Board in the place of Professor John Davis who was our founding Chairman. Another keynote speech was given by John Bowis, the then Minister of Health, who outlined the support from the Department of Health for voluntary registration.

There is no statutory regulation of psychotherapy but the Department of Health encourages self regulation and recognises the BCP as a registering body. As Andrew Elder put it,

The establishment of the BCP is a helpful step towards the public (and members of the health professions) being able to make more careful distinctions between the widely differing degrees of training for psychotherapists. Anyone in the Blue Book has had a training from one of a group of the most substantial trainings available in psychotherapy. I hope that its availability has been made widely known.

The BCP council and the Advisory Board have been concerned about the lack of information about psychoanalytic psychotherapy in the regions. An audit of enquiries to the BCP office showed that 2-3 of them came from outside London. A pilot project was set up in 1998 in the Oxfordshire, Buckinghamshire and Reading areas to see how understanding can be effectively increased. In your information folders which accompany this presentation is the latest Newsletter of the BCP and also brochures on Psychoanalytic Psychotherapy and Finding a Therapist.

The brochures are available in quantities free of charge and may be displayed in surgeries, clinics, libraries where there is a rack or table for literature of this kind.

In setting up the pilot project we were aware of the danger of creating a demand which might be difficult to fill. By its nature the work is often long term and it can be difficult to find therapists with vacancies. At the same time it is important that information on effective treatments should be available to referrers and patients even if there may be problems of supply. And sometimes treatment can be arranged quickly. There are treatment places through reduced fee schemes for those needing treatment three or more times per week. How available these are varies according to the region concerned.

First a word about how psychoanalytic psychotherapists develop. Training with a BCP organisation is usually done as a second profession; almost all on the BCP Register have first trained in a core profession such as psychiatry, psychology or psychiatric social work or, less commonly, as nurses or counsellors. These are the professional bodies on our Advisory Board. 60% of those on the Register currently work in the public health services and many of the rest did so in the past but unfortunately there are few posts available. The interest in public sector or amongst BCP registrants is very strong. Two of our member societies are located primarily in the public sector - the Tavistock Clinic, and the Association for Psychoanalytic Psychotherapy in the NHS. We also register members of the Association of Child Psychotherapists. The percentage of those working in the public sector would be substantially higher than 60% if there were more opportunities. Perhaps this will develop as new funding arrangements evolve. As will be appreciated from this background in core public sector professions, practitioners have their roots in a breadth of experience both of conditions which patients bring and of resources for dealing with them. So when someone is referred to a psychoanalytic psychotherapist, the first thing which will happen is an assessment as to whether this form of treatment is the most appropriate. Those taking part in compiling this presentation are typical of BCP registrants having first trained in one of these core professions, all of us worked in the public sector and 3 of us (60%) currently do so as well as working privately. Training as a psychoanalytic psychotherapist is long and intensive involving personal analysis at three or more times weekly and treatment of patients under supervision at a similar frequency. Work in the public sector which is often shorter term and less intensive is informed by training to these requirements and may be seen as an application of psychoanalytic psychotherapy.

Psychoanalytic psychotherapy is a treatment which requires a great deal of investment of time and money (whether in the private or public sectors). In addition to thinking about the sort of patients who require the investment in time and money required, other questions are, What are the differences from counselling? What is the transference? How does psychoanalytic psychotherapy work? Why is it necessary to attend sessions more than once a week and why does it take so long? Is there evidence based research as to its efficacy.

These are the questions which make up the other part of this presentation. We would like this to result in an ongoing dialogue and the BCP would be happy to receive feedback.


Part Two

What are the differences between Psychoanalytic Therapy and Counselling? - Jacqueline Ferguson

There is often concern that psychoanalytic psychotherapy might encourage an unending dependence of the patient upon the therapist. However, a more careful examination of this cartoon reveals a different truth. When things go well during the course of a psychoanalytic psychotherapy or psychoanalysis, patients internalise the relationship with the therapist. This internalisation not only supports them during the therapy, survives the end of the therapy, and the death - real or metaphorical - of the therapist, but continues to grow afterwards so that the patient becomes stronger, more able to be truly independent, and also less liable to fall ill, than they were before therapy.

The therapy does this by addressing unconscious aspects of the patient which feel unacceptable to him or her. This itself can give rise to some discomfort about psychoanalytic psychotherapy, with the question: "is this really good for you?"

Levels of psychotherapy

Cawley's idea of a gradation in levels of psychotherapy helps provide a framework for thinking about the differences between psychoanalytic psychotherapy and counselling. He suggests a variation between two poles of intensity of work. At the outer level, lies supportive therapy and Carl Rogers' person centred counselling, while at the deepest pole, lie psychoanalytic psychotherapy and psychoanalysis. In between, work may be at various levels, often using psychoanalytic concepts to inform a psychodynamic counselling or psychotherapy.

However it is not a simple continuum. There are major differences between levels 1 and 9, and an understanding of these differences can help GPs think about the patient's needs and the sort of therapy appropriate to them.

Levels of Psychotherapy
Cawley's levels

1 outer
(support and counselling)
1 Unburdening of problems to a sympathetic listener
2 Ventilation of feelings within supportive relationship
2 Intermediate 3 Discussion of current problems with non-judgmental helper
4 Clarification of problems, their nature and origins, within a deepening relationship
5 Confrontation of defences
3 Deeper
(exploration andanalysis)
6 Interpretation of unconscious motifs and transference phenomena
7 Repetition, remembering, and reconstruction of past
8 Regression to less adult and less rational functioning
9 Resolution of conflicts by re-experiencing and working them through within therapeutic relationship

While the terms counselling and psychotherapy can be confusing and are sometimes used interchangeably, there are major differences in aim and method between counselling at the outer level and analytic psychotherapy. These differences affect the decision about the kind of patient for whom these approaches are suitable, the duration of the therapy and the length of training necessary to practice it.

Counselling at the outer level, is non-exploratory in the sense that it does not challenge the patient's defences or explore unconscious material. Instead the counsellor's method is one of empathic listening, reflection and problem solving, with the aim of restoring clients to their state of mind before they became ill, and to help them recover their previous ability to cope. By contrast, analytic psychotherapy aims for deep seated and permanent structural changes within the personality. Processes of maturation and integration which have previously been held up, are through this method, encouraged to resume. Analytic therapy addresses and focuses on the products of unconscious levels of the mind, through interpretation of dreams, anxieties and defences, and of the transference. It often involves the use of the couch.


A comparison of counselling with analytic psychotherapy

Counselling

Analytic Psychotherapy

Non-exploratory

Exploratory

AIM

Restore status quo

Structural change

Restore coping skills

Personality maturation, integration

METHOD

Reflecting

Free association

Problem solving

Interpretation

Defences

Transference

Dreams

FOCUS

Conscious

Unconscious

FOR WHOM?

Self limiting crisis

Repeated dysfunctional patterns of illness; psychosomatic problems, relationships etc.

No major peronality factors

Symptoms seen as function of personality or unconscious conflict

Ill. Poor toleration of anxiety; fragile defences need support

Ill, but responds to interpretation by integration

Patient's preference

Motivated, capacity

HOW LONG?

Weeks or months

Months or years

TRAINING

Variable 2-3 years

4-7 years

Personal therapy optional x 1-2/week

Personal analysis x minimum 3-5/week

Different patients benefit from these very different approaches. Counselling may particularly benefit those patients who have a self limiting crisis, helping to ensure a better outcome in a shorter period of time. It can also be suitable for very ill patients, whose fragile defences need support, perhaps intermittently over long periods. Counselling can help patients with personality difficulties where these do not contribute in a major way to the symptoms or to the patient's response to treatment.

Analytic therapy, by contrast, is often indicated for those patients whose symptoms seem to be a function of their personality difficulties or of unconscious conflicts. This may appear in the form of repeated dysfunctional patterns, e.g. in relationship in patients' personal lives or with the doctor or in the response to illness and treatment. Psychosomatic illness, hypochondriasis, major neurotic illness and personality difficulties may need psychoanalysis or a psychoanalytic therapeutic approach.

Many patients want to understand themselves and what underlies their symptoms, rather than simply have these symptoms relieved. Such patients should be considered for psychoanalytic psychotherapy. A psychiatric diagnosis in itself is not a good guide to whether or not someone might benefit from psychoanalytic psychotherapy. This may help patients with a whole range of symptomatic presentations. It is more a question of the motivation and the capacity of the patient to use this approach.

The differences in approach have been compared to that between a house needing the services of a painter and decorator, as opposed to one needing structural alterations and repairs, perhaps affecting the foundations. A key to understanding this structural process is an understanding of the transference.

ACKNOWLEDGEMENTS

Cartoons and illustrations used by kind permission of the copyright holders:

* Taylor & Francis for Robin Skinner and John Cleese - copyright Families and how to survive them, first paperback edition 1984.

** Curtis Brown for Mel Calman copyright Mel Calman 1997

*** Taylor & Francis for Bryan & Pedder - Introduction to Psychotherapy 2nd Edition 1991


Part Three

What is Transference? - Andrea Watson

When we are thinking about how to effect this structural change that has been mentioned, we start from the premise that the way we respond to events that occur in the external world is crucially affected by the state of our internal world, the world of our imagination and unconscious processes.

We build up a picture of that internal world over a period of time, with children through play and verbal communication and with adults through dreams and verbal communication. A great deal of this material will be about the nature and state of the relationships but that relationship itself is based on earlier internalised relationships that are transferred on to the person of the therapist by the patient. The therapist is incorporated into the patient's "inner world" drama which is enacted in the transference. This process inevitably stirs up anxieties, conflicts and difficulties and if this does not occur the therapy is unlikely to have impact. Our aim is to contain the disturbance within the therapy where it can be thought about and understood. At the beginning of the treatment the patient's perception of the therapist can be very distorted. The transference interpretations and the constant checking against the real figure of the therapist leads gradually to a more realistic perception and permits normal developmental processes to resume. Confusions, misunderstandings and mistrusts surrounding the relationship with the therapist can be clarified in the course of treatment. It is through the deepening understanding of this transference that structural changes take place. A question might arise - how does one know that what the patient is commenting on is in this transference relationship, and not an objective comment about oneself? This is clearly where the therapist's own analysis plays a crucial role in distinguishing one's own psychological make-up from that of the patient and thus being able to keep a check on one's own counter transference.

Such an understanding that this is transference also protects the therapist from either being cast into despair by a critical attack or made big-headed by praise when, somewhat more rarely, that may occur.

Another question might be: Why do therapists withhold personal information?

In order to be available to one's patient as someone onto whom and with whom such fantasies can be developed and explored at depth most of the content of the therapist's actual external life has to be kept separate from the patient. This is not through any desire to be mysterious or provocative but only so that the task that one has been asked to undertake can be completed most effectively. If too much is known about the reality of the therapist's life fantasy will inevitably be curtailed and the therapeutic conversation will be closed down.


Part Four

Why such a long time? - Philip Roys

A question frequently asked about or, more accurately perhaps, a criticism frequently levied at, Psychoanalytic Psychotherapy is that treatment takes a long time. We are familiar with the jokes and jibes by and at Woody Allen for example. Now such jokes can be cheap but they do contain a kernel of truth; psychoanalysis and psychoanalytic psychotherapy are not short-term treatments. I think responsible practitioners would seriously question the validity of therapy which lasted a lifetime, but therapies lasting several years are not uncommon, with two to four years being a pretty average length of time.

A further related question is sometimes raised. Why do patients need to attend their therapy more than once a week? It is unusual for other therapies to require sessions more than once weekly, but in psychoanalytic psychotherapy this is the norm; two times and even five times weekly are typical frequencies.

There are good reasons for such an investment of time and money. Firstly, the aim of psychoanalytic treatment is a reshaping of fundamental psychic structures. These structures will have existed for many years and will be held on to by the patient, despite the fact that they are likely to be contributing to the presenting difficulties. Much of this resistance to change will be unconscious and, therefore, appeals to rationality will be unlikely to succeed. It is as if unconscious parts of the personalities follow the maxim "Better the devil you know".

Brief work with such structures is unlikely to be successful. An important part of psychoanalytic theory concerns the (largely unconscious) parts of the personality which will oppose change and development and seek to maintain the psychic status quo. Such defensive structures have been established for good reasons, typically to defend against pain and anxiety. Once the psychotherapist starts to confront them, the patient will need a great deal of support if he is to cope with the pain and anxiety which fuelled their establishment. There will be a tendency for the patient to cling on to the familiar defensive structures in order to avoid pain and this tendency will need to be confronted by the therapist. However, unless the patient is helped to be able to bear whatever it is that is being defended against or at least develop different ways of coping with it, change and development will not be possible.

I hope this gives a flavour of what the patient and psychotherapist are wrestling with and of why such an investment of time is required. Once weekly sessions may not be sufficient, as the patient may simply re-erect familiar defences against pain in between sessions, effectively blocking any change or development. More frequent sessions may diminish this tendency to hold on to familiar patterns; the psychotherapist, being more available, is able to offer more effective support to the part of the personality which is able to face change and development and cope with the conflict and distress to which this may give rise. Some patients have a tendency to "act out" - expressing their distress by action in their everyday life and relationships, and sometimes causing a great deal of anxiety and distress to those with whom they are involved. For such patients, intensive psychotherapy may be essential if the emotional turbulence is to be contained within the therapy rather than being enacted outside it.

What then do we ask of patients who present for psychoanalytic psychotherapy? In the first place, although (especially in intensive therapy) a great deal of support may be available, they must be able to tolerate the anxiety and distress which will be stirred up with the therapy. Secondly, it is helpful if they have some concept of an "inner world" which they are interested in exploring. This is not an essential pre-requisite, as some patients can develop such an interest over time, but it is hard to conceive of a patient fully engaging in analytic therapy who is not interested in his inner world. Thirdly, patients must have the time and (if it is a private treatment) the necessary funds to attend sessions. Obviously, for some patients this is easier than for others, but many psychotherapists in the private sector have times in the early morning or early evening to accommodate patients who cannot attend during the day, and some operate a sliding scale for their fees.


Part Five

Research on Psychoanalytic Psychotherapy
What kind of evidence do we have? - Jean Knox

'NHS Psychotherapy Services in England'
a Department of Health Review

IN September 1996 the NHS Executive published a review document entitled NHS Psychotherapy Services in England, partly in response to the rising demand for counselling and psychotherapy in primary and secondary care. This document recognises clearly the importance of psychotherapy, stating on the first page that "people with severe neuroses and personality difficulties require appropriate psychotherapy outpatient treatment in liaison with the GP and other mental health staff involved" and that "Formal psychotherapy services have an important role in provision and raising standards of practice through training, supervision and consultancy".

Another key theme of this document is that evidence based practice in the psychotherapies requires a much better research foundation than is currently available; whilst there has been much more research done on the effectiveness of cognitive and behavioural approaches, these also require further research evidence as to their effectiveness. The point is also made that there is an urgent need for controlled research on the clinical effectiveness of psychoanalytic therapies and "short-term symptom relief, whilst of value, is not a sufficient measure of improvement; reliable measures of changes in core interpersonal conflicts, general functioning and quality of life will be important". This document therefore sets an agenda for psychotherapy research.

A bibliography of research evidence

Jane Milton, Consultant Psychotherapist at the Tavistock Clinic, has published a bibliography which gives detailed references for the kind of research which the DOH is calling for, some of which is already available. (Milton 1996).

Some key papers on the effectiveness of psychoanalytic psychotherapy

1. A study published in 1997 from Stockholm pointed out that in a literature survey of 796 studies on the effects of psychotherapy, only 20% of these investigated therapies of more than 20 sessions and only 9% were concerned with psychoanalytically orientated therapies. The authors of this Stockholm study themselves conducted a study of two groups of patients who were in psychoanalysis of psychotherapy over 4-4½ years and who were followed-up for 3 years. Amongst many other findings, they found increasingly positive effects of treatment with length of follow-up, especially in the psychoanalysis group; (Sandell et al 1997).


2. A study by Siassi compared psychoanalytic psychotherapy with behavioural or eclectic psychotherapy; a key point in this study is that the design was such that experienced clinicians in the respective mode of therapy were free to apply their own methods in their own way. Clear advantage is shown for psychoanalytic therapy particularly in the long-term follow-up, with significant improvements on the measures included in the original assessment (Siassi 1979).

Cost effective studies

1. Good quality controlled trials of psychoanalytic psychotherapy have shown that it can reduce dependence on health services in patients with a range of physical illnesses such a irritable bowel syndrome, post myocardial infarction and brittle diabetes (Guthrie et al 1991; Gruen 1975; Moran et al 1991).

2. A study of patients receiving psychoanalytic psychotherapy for a range of psychological problems found that there was a reduction in general practice use by those who receive treatment compared with a non-treatment group and that costs compared favourably with other forms of treatment (MacDonald 1992).

3. Research in progress - The Association of Psychoanalytic Psychotherapy in the NHS (APP) has set up a project in which twenty-five NHS psychotherapy centres will collaborate in a prospective study of different psychoanalytic psychotherapies given within psychotherapy departments, including short-term therapy, long-term psychoanalytic therapy and group therapy. Around 2000 subjects will be recruited so that this will be one of the largest studies of its kind. Well-planned studies on the effectiveness of long-term psychoanalytic psychotherapy are underway in the Universities of Basle and Heidelberg. The Helsinki Psychotherapy Study, started in 1995, is a randomised clinical trial evaluating the effects of four types of psychotherapy, short and long term, in the treatment of depressive or anxiety disorders and the first evaluations will be carried out in 2000 and 2002.

The reliability of the psychoanalytic judgements used in assessing patients for psychotherapy

Research tools can also be used to test psychoanalytic theory as well as clinical effectiveness:

1. Professor Peter Hobson and his colleagues from the development psychopathology research unit at the Tavistock Clinic showed that psychoanalytic ideas are grounded in clinical phenomena that are available to public scrutiny and appraisal (Hobson et al 1998). They showed that it is possible for independent assessors to agree in rating psychoanalytic aspects of the interpersonal relatedness, using a standardised 20 - item "Personal Relatedness Profile" to rate videotaped interviews with borderline and dysthymic patients; furthermore the pattern of ratings conformed to those expected from psychoanalytic descriptions of patterns of interpersonal relationships in the two diagnostic categories.

2. Other theoretical research drawing on Attachment Theory, has been conducted by Professor Peter Fonagy of the Psychoanalysis Unit at University College London together with colleagues at the Anna Freud Clinic. Fonagy used Mary Main's Adult Attachment Interview to demonstrate that each parent's early attachment experiences contribute to a model of relationships which affects all subsequent relationships, including their capacity to respond sensitively to their child and this in turn crucially affects the child's security of attachment to each parent, as measured by the Ainsworth Strange Situation (Fonagy et al 1993).

Psychoanalytic psychotherapy for children

Finally, I turn to the question of the effectiveness of psychoanalytic psychotherapy for children. One study which might be of particular interest to General Practitioners is that conducted by Professor Fonagy and his colleagues, showing that 13-14 year old children with dangerously uncontrolled diabetes who receive psychoanalytic psychotherapy had lower blood sugars than the control group who received the same medical care but were not in therapy. Follow-up over one year showed that the psychotherapy treatment group sustained the improvement in blood sugars whereas the control group returned to pre-hospitalisation levels of problems within three months (Moran et al 1991).

A major retrospective study of the case notes of 763 children treated at the Anna Freud centre over 40 years showed that over 85% of children with anxiety and depressive disorders not longer suffered any diagnosable emotional disorder after 2 years treatment and 69% of children with disruptive behavioural disorders no longer warranted any diagnosis after a year of therapy (Fonagy and Target 1996).

I have only been able to highlight a few of the research studies on psychoanalytic psychotherapy, but I hope they offer enough information to indicate that there is significant and reputable evidence for the effectiveness of this form of treatment when the right kind of questions are built into the research structure. Much more is needed to build upon the best of information which we already have and such studies are underway.


REFERENCES

Fonagy, P et al (1993). 'Measuring the ghost in the nursery; an empirical study of the relation between parents' mental representations of childhood experiences and their infants' security of attachment'. J. Amer. Psychoanalytic Assn. 41, 957-989.

Fonagy, P, Target, M. (1996) 'Predictors of outcome in child psychoanalysis: a retrospective study of 763 cases at the Anna Freud Centre'. J. Amer. Psychoanalytic Assn. 44,(1) 27-73

Gruen, W. (1975) 'Effects of brief psychotherapy during the hospitalisation period on the recovery process in heart attacks'. J. Cons. Clin. Psychology 40, 223-232.

Guthrie et al (1993). 'A Randomised controlled trial of therapy in patients with irritable bowel syndrome'. British Journal of Psychiatry 163, 315-321.

Hobson, P. et al (1998). 'Objectivity in psychoanalytic judgements'. British Journal of Psychiatry, 173, 172-177.

MacDonald, A.J. (1992). 'Training and outcome in supervised individual psychotherapy'. British Journal of Psychotherapy, 8, 237-246.

Milton, J. (1996). 'Presenting the case for psychoanalytic psychotherapy services. An annotated bibliography'. Produced by the Tavistock library.

Moran, G.S. et al (1991). 'A controlled study of the psychoanalytic treatment of brittle diabetes'. J. Amer, Academy of Child and Adolescent Psychiatry, 30, 241-257.

Sandell, R. et al (1997). 'Findings of the Stockholm Outcome of Psychotherapy and Psychoanalysis Project (STOPP). Paper presented at the annual meeting of the Society for Psychotherapy Research, Geilo, Norway, June 25 1997.

Siassi, I. (1979). 'A comparison of open-ended psychoanalytically orientated psychotherapy with other therapies'. Journal of Clinical Psychiatry, 40, 25-32.

 


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