Why Psychoanalysis?

by Irwin Hirsch, PhD

Psychoanalysis has changed and psychoanalytic training is more relevant than ever. Indeed, the psychoanalytic process continues to adapt to a contemporary climate in which there is increasing need for talented and well-trained clinicians. I begin by describing my view of what psychoanalysis is, circa 2015, and proceed to address the importance of high level and intense training.

Psychoanalysis, before the Relational (one can also say Interpersonal) turn in the 1980s, used to be defined by what prominent analyst Merton Gill called extrinsic criteria. Those criteria essentially referred to therapy consisting of 3 to 5 times per week meetings, the obligatory use of the couch, and the number of years’ duration of the treatment. Though some patient-analyst pairs still meet these extrinsic criteria, I agree with Gill that this says very little about the essence of the process. He suggested that the essence of psychoanalysis consists of efforts to understand patients through the vehicle of transference, that is, the way patients unconsciously convey who they are by the way they relate to the therapist/analyst. I would add that this understanding is inherently subjective and to a fair extent based on countertransference experience, i.e., how the analyst as a second subjective other perceives and engages each unique patient. Patterns of relatedness, as described by another iconic psychoanalyst Edgar Levenson, can be clarified by drawing parallels between the way each patient engages the analyst and how this may isomorphically line-up with the way the patient describes engaging with others in their current universe and the way the patient and his or her significant other caretakers engaged with one another developmentally.

Though multiple meetings per week provide an intensity and an ideal gauge of the way each patient unconsciously engages the world of others, the aims of psychoanalysis can be achieved by sensitivity to the transference-countertransference relationship even in the context of once weekly meetings. And the couch, once a psychoanalytic staple, is no longer employed by a significant number of trained analysts. Indeed, the main reason Freud used the couch was because being directly looked at all day long was less comfortable for him than otherwise. In addition, being seen by patients interfered with his freedom to use his mind creatively. This is still a good reason for one to place patients on the couch, though many practitioners find that they are more alert and focused when making direct eye contact. Many contemporary analysts today believe that the use of the couch is entirely optional and should be based on what makes each unique individual analyst likely to do their best work.

The traditional third extrinsic criterion, a treatment of long duration ultimately leading to mutually agreed upon dramatic personality change, has also modified in the hearts of so many analysts who no longer see a binary relationship between neurotic and normal, ill and well. Again, though most analysts prefer their patients to stay until a mutually agreed upon termination, many of us also recognize that the pragmatics of life—time, money, physical health, geography and the like often prohibit ideal analytic situations. Many contemporary psychoanalysts recognize that patients may change to a degree in less than ideally terminated time periods and that change itself moves along a continuum and does not entail a shift from one pole to another. The idea that the well-analyzed person can be completely healthy and free of psychological problems now has the status of an exploded myth. As well, it is quite common for patients who have experienced benefit to stop and return to analysis at a later date, often in the context of experiencing new difficulties in life.

To the extent that so many contemporary practitioners no longer hold to the old extrinsic criteria, the binary of what is and what is not psychoanalysis rests more on the intrinsic criteria, in particular, the use of the transference-countertransference relationship as a primary vehicle for understanding people and for helping them change along a continuum. Analysts have recognized for some time now that most people have neither the time or money, much less the willingness, to engage as patients 3-5 times weekly for many years consecutively. In fact, very few people outside of analytic candidates (who are required) choose to do this anymore, and a strong majority of us see the majority of our patients once or twice weekly. This reflects an adaptation to the contemporary world as it is, as well as the shift I have described away from binary thinking and an embrace of intrinsic as opposed to extrinsic values. In this less strict and perfectionistic context, one can say that many more patients are available to be analyzed. Indeed, by this standard I and many others safely claim that all of our patients are analytic patients.

So, what is the value of initiating psychoanalytic training that requires 3-5 times per week personal analysis and treating x number of patients 3-5 times per week for an extended period? On the surface this easily appears hypocritical and short on common sense. The strongest argument for maintaining the above training model is to create an experience that exists under ideal conditions (multiple sessions per week) as a vehicle for subsequently working, for the most part, under less than ideal conditions. The most direct way to learn to become an analyst is to be a patient in analysis while simultaneously, under supervision, seeing patients in the context of using that very same model.

Psychoanalysis is the most thorough way to help people understand themselves, grasp the unconscious motivations that cause trouble in life and to change the fabric of one’s internal world, a world developed through a life history of engagement with significant others. Other models of therapy do not go as deep, if you will – they focus more on changing external behavior without addressing the unconscious motives that maintain and perpetuate the behavioral problems each of us has to one degree or another. Freud postulated that life is inevitably filled with sadness, tragedy, illness and loss; these are often problems that are unavoidable. The aim of psychoanalysis is to address those problems that we unconsciously make for ourselves, i.e., life is hard enough as it is. Examining unconscious motivation and sensitivity to understanding people in part by how they relate to us (transference) is difficult and takes a long time to learn how to do well. Any other therapy modality is far faster and easier to learn. Furthermore, people do not change by understanding alone. The intense relationship between analyst and patient in and of itself becomes a new and significant relationship for each patient. Ultimately and ideally the psychoanalytic relationship is a mirror of other significant relationships, and when this is examined, patients have the opportunity to internalize new and different life experience with a new significant other – the analyst.

As the reader can see, this process is complex, and because the aim is to shift what has been internalized by a long life history with others, it is also ambitious. No other therapy modality has quite the same ambitions, and no other modality addresses the human psyche in such depth. For this reason alone psychoanalytic training is longer and harder than any other – it helps create the capacity to understand people in greater depth than can be achieved by any other means of which I am aware. It is the best quality product one can buy for both the candidate in training and the patients who stand to benefit most profoundly by working with those with the highest level of education and skill. Now that the psychoanalytic process has adapted to the exigencies of contemporary life, more candidates are available for training, and more patients stand to benefit from those who are the most educated and skilled therapists.

Irwin Hirsch, PhD, a founder of the Manhattan Institute for Psychoanalysis is teaching and supervising faculty at the Manhattan Institute for Psychoanalysis and other institutes and is in private practice in Manhattan.