Upsetting Psychotherapy

Scientific American
September 21, 2005

Pressure from insurance companies and competition from drug therapies
are prompting analysts to get patients off the couch more quickly

By Jamie Talan

Wendy spent five years in psychoanalysis, delving so deeply into her
mind that she could no longer see the connection between her adult
problems and her teenage episodes of "cutting" her wrists. After she
and her analyst had their final session, during which he welcomed her
to move on with her life, Wendy was not completely happy, but she was
happier than she ever had been. And that, psychologists say, is
successful therapy.

Psychoanalysis probes the unconscious mind to unlock the mysteries
that drive conscious emotions and behavior. The discipline is built on
pillars set by Sigmund Freud a century ago. It is characterized by
frequent sessions that can take place over many years, wherein
patients are encouraged to freely associate whatever comes to mind as
the analyst sits quietly and listens.

Today the practice is changing. The transformation is in part the
result of a better understanding of what works during self-analysis.
But increasingly, psychotherapy is changing just to survive, held
hostage to limits on insurance coverage determined by managed care
companies and facing replacement by psychoactive drugs that in the
long run are far cheaper than a patient's weekly visit to the
therapist's office. In this incarnation, it suddenly matters less that
symptoms may disappear without patients figuring out the underlying cause.

Harsh Reality
To keep psychoanalysis alive, contemporary therapists are revamping
Freud's theories. They have discarded some traditional beliefs and
have loosened requirements so patients can succeed in fewer sessions.
Many analysts are even talking to their patients and sharing their own
thoughts and feelings, a practice that Freud said would complicate the
treatment process.

Some experts chafe at the changes, however. They say that short-term
therapy can be successful for some problems such as phobias but does
not work for personality disorders, chronic depression and other
substantial mental illnesses. They claim that managed care companies
make decisions based on cost, not on any science that shows what works
best for a specific condition. Insurance companies argue that patients
can do just as well on medication as they can with talk therapy and
that for talk, "short term" is enough.

Extended analysis certainly is under siege. Today patients having
long-term psychotherapy--more than 20 sessions--account for only 15
percent of those who seek treatment, according to a study in the
American Journal of Psychiatry. Psychoanalysts contend that it takes
longer to work out issues that have been shaped by a lifetime of
emotion and experience, yet they know they must compete in a
magic-pill era in which people may be content to have their symptoms
disappear without much thought to why they emerged in the first place.

"A better understanding of the self is needed for a better recovery,"
asserts Gail Saltz, a Manhattan analyst and author of Becoming Real
(Riverhead Trade, 2005), a book about the benefits of analysis. She
says that there are still people who lie on the couch four times a
week, but many analysts have accepted a once-a-week regimen. And
although studies have shown that certain patients progress better when
therapy is frequent, Saltz believes once a week can still be
successful. Psychologists have at least agreed that even long-term
analysis should be completed within four years.

Patients may be content to have symptoms disappear without much
thought to why they ever emerged.

Regardless of frequency, Saltz says, the goal is to help patients
"better tolerate the ups and downs of life" or, as Freud put it, "get
beyond everyday human misery." Freud developed his ideas before
scientists knew much about the brain's workings, however, and today
some of his once popular theories about human development are seen as
simply wrong.

High on the list is that infants have complicated sexual desires.
Peter D. Kramer, a Massachusetts psychiatrist who popularized the new
generation of antidepressants in his best-selling book Listening to
Prozac (Penguin, 1993), says that "there is no evidence that infants
have sexual desires." Kramer notes that although Freud believed that
adult complaints of childhood sexual abuse stemmed from such childhood
fantasies, the evidence today is plain that sexual abuse of children
is common, affecting up to 20 percent of girls and 10 percent of boys.

Freud also had little to offer the therapist in understanding trauma,
which experts now know can cause lifelong problems. Trauma therapy is
a relatively new field, built on work with war veterans.
Post-traumatic stress disorder is a hot topic in psychotherapy today,
one that was poorly addressed before, Kramer notes, because it was not
possible to have effective treatment when the theoretical
underpinnings were shaky.

Friend, Not Father
Readdressing the basic tenets of psychoanalysis has led to perhaps the
most radical change of all: modern psychologists are actually talking
to their patients. Freud's original "transference" theory demanded
that an analyst remain quiet and aloof so as to serve as a "screen"
onto which the patient could project her emotions. But therapists are
now sharing more of themselves. "How can I remain opaque when my
clients can go online and learn that I love Greek music?" asks
psychoanalyst Spyros D. Orfanos, clinic director in psychoanalysis at
New York University.

Orfanos says that today's analyst is not an authoritative father
figure but a partner in figuring out "the powerful emotional forces
that drive behavior." He thinks that having a dialog with a patient
is the best way to work toward change. Many analysts also now agree
that empathy is key to the relationship, and empathy requires
engagement, not just listening.

Psychoanalysis is also changing in the face of steady competition from
other forms of help, such as cognitive behavioral therapy, in which
patients try to change certain troubling behaviors, and goal-oriented
therapy, which lays out ways to attain, say, certain kinds of
relationships. These practices may or may not touch on the patient's
past. And to hold its own, psychoanalysis is shedding its image as a
privileged treatment for the wealthy; so-called training centers are
popping up everywhere that provide low-cost appointments.

Scientists are also attempting to study the biology of the analysis
process itself. At New York-Presbyterian Hospital/Weill Cornell
Medical Center, psychiatrists Otto F. Kernberg and David A.
Silbersweig are recording brain scans of patients before and after
analysis. Such studies may help end the debate over the effectiveness
of lengthy treatment, notes Kramer, who recently published Against
Depression (Viking Adult, 2005), an assessment of mood disorders. "We
don't know what works or what doesn't work."

Orfanos is dubious about scanning, maintaining that analysis is a
humanistic endeavor that does not necessarily fit into a biology-based
medical model. "It's about understanding how your mind works," he
says, "so that you can have more choices in your life."