Psychoanalytic psychotherapy

What it is

Psychoanalytic psychotherapy is the most exploratory of the talking therapies. It works in depth with unconscious processes, and is usually open-ended rather than fixed to a set number of sessions.

It is a shame that Sigmund Freud has become something of a caricature in popular culture. The cartoons are often funny, but they add ridicule to ideas that profoundly changed how we understand ourselves. The unconscious, the meaning of dreams, the notion that our behaviour is shaped by our past and not only by our brains — this language runs right through modern life. Perhaps there is something uncomfortable about being reminded that we are not as in control of ourselves as we like to think.

The popular view has also simplified psychoanalysis into an out-dated body of knowledge set down a hundred years ago. The reality is quite different. Psychoanalysis has continued to grow, made up of several related strands of thinking about the human personality, most of it generated in response to clinical work rather than theory. It is neither dogmatic nor unchanging.

As a treatment, psychoanalytic psychotherapy is most useful for people struggling with longstanding difficulties in how they think and feel about themselves, the world and their relationships. Shorter-term approaches can help a great deal with recent experiences of anxiety or depression, where a trigger is easier to identify — a relationship ending, the loss of a job. For difficulties that have been present far longer, and may have begun early in life, an approach that takes time and works towards the bigger picture is often what is needed.

If you stopped now and spent a few minutes noticing your own thoughts, feelings and sensations, what you found would give a glimpse of the very particular way you have of seeing the world. You would probably also notice how rarely modern life offers that chance. A psychoanalytic psychotherapist is trained to create a space and a kind of attention that encourages exactly this reflection — listening and observing over time, gradually building a picture of how you see yourself and others, and feeding that understanding back in ways you can think about together. It sounds simple. Having someone to think with us about things helps us to think about things.

The metaphor of the iceberg remains a useful one: what we show on the surface is the tip, and much stays beneath it. Repeating a pattern of behaviour even when it does not serve us is something most people recognise. The analysis of dreams became the classical route to the unconscious, but Freud held that we all catch sight of it in ordinary life through what he called bungled actions — the slips of the tongue that say what we really meant before the conscious mind can censor them.

The therapeutic setting creates conditions for that material to surface: the safety and reliability of the same room at the same time each week. In traditional analysis the client lies on a couch with the therapist sitting out of view, to free the process of free association from self-censorship, and attendance may be three to five times weekly — a frequency that keeps the link between unconscious and conscious alive from one day to the next. Melanie Klein adapted the method for children, using play as a symbolic, pre-verbal form of free association.

That work with children opened new strands: attachment theory, the British school of object relations, and the inter-subjective and relational approaches practised widely today. The unconscious and repression remain at the core, but we now understand far more about the importance of our earliest relationships — the interaction between a newborn's temperament and the emotional capacity of those caring for them, and how that shapes development into adult life.

Infant research has since provided evidence for those early bonds. We are born drawn to eyes, faces, voices and smells, preferring the familiar; newborns imitate expressions and are calmed physiologically by touch. Where a parent can tolerate and make sense of a child's distress, the child gradually develops that capacity themselves. Where the environment could not provide that — through no fault of anyone's, often because of a parent's own anxiety or depression — the effects show in emotional development later on.

Neural pathways are laid down from our earliest experiences, but they continue to be made throughout life. When things were not ideal, the relationship with a psychoanalytic psychotherapist offers a chance to think about those experiences again, and in the thinking and re-experiencing, for something reparative to happen.