What is psychoanalysis?

Where the method comes from

Psychoanalysis is the oldest of the procedures billable today and the only one to have shaped an entire culture. Its terms have passed into everyday speech: repression, Freudian slip, the subconscious. Hardly anyone who uses them still knows where they came from.

It begins with a book. In 1895 the Viennese internist Josef Breuer and the neurologist Sigmund Freud published the Studies on Hysteria.¹ In it stands the founding assumption that carries everything else: a symptom is not a defect but an expression. It stands for something that may not be thought, and therefore takes the detour through the body or through an anxiety. Make the repressed conscious, and the symptom loses its purpose.

Out of this assumption Freud built, over the following decades, a structure of theory and technique that stands to this day. In Germany psychoanalysis became a benefit of the statutory health insurance system in 1967, under the name analytical psychotherapy — together with psychodynamic psychotherapy, and twenty years before behavior therapy.²

The founding case — and what the archives show

Every doctrine of treatment has a case with which it begins. For psychoanalysis it is Anna O., in civil life Bertha Pappenheim, treated by Breuer between 1880 and 1882. It was she who named the method: the talking cure. In the Studies on Hysteria the case is presented as a success.¹ Freud later spoke of a successful cure and of a great therapeutic achievement.

In 1972 the medical historian Henri Ellenberger found, in the archive of the Bellevue sanatorium at Kreuzlingen on Lake Constance, the case history Breuer had written in 1882 — immediately after concluding his treatment, and thirteen years before publication.³ Building on this, Albrecht Hirschmüller found further documents, among them a supplementary report by Breuer.⁴

What emerges from them is plain. Breuer referred Bertha Pappenheim to Kreuzlingen on July 12, 1882, and did not attend to her personally thereafter. She was not free of symptoms at that point. It took years before she was restored to health; as late as 1887, five years afterward, Martha Bernays — Freud's fiancée and an acquaintance of the family — wrote that she was still ill.

The case that founded the talking cure was, at the moment of its publication as a cure, no cure. The demonstration comes not from opponents of the method but from the archives, and it was carried out by the historian whose account of dynamic psychiatry is regarded as authoritative to this day.

Bertha Pappenheim later became a significant social reformer and the founder of the League of Jewish Women. By what means she finally recovered is not documented.

How a psychoanalysis proceeds

The patient lies on a couch; the analyst sits behind him, out of view. This arrangement is not a ritual but a technique: it is meant to turn attention inward and to switch off the other person's facial expression as a steering signal.

The fundamental rule is to say everything that occurs to one — without selection, without regard to whether it seems embarrassing, unimportant or absurd. This is free association. The analyst listens with evenly suspended attention and interprets: he names patterns, repetitions and omissions, and draws connections to earlier experience.

Two concepts define the work. Transference means that the patient develops feelings toward the analyst that properly belong to earlier figures in his life — and that precisely in this the old pattern becomes visible and workable in the consulting room. Resistance means everything the patient sets against this: silence, arriving late, doubts about the method.

The treatment is long and dense. The Psychotherapy Guideline provides for up to three hours a week⁵; up to 160 hours are authorized first, and up to 300 at a second step.⁶ At two hours a week that comes to roughly three years. It is by a wide margin the largest allowance of all four guideline procedures.

Psychoanalysts give no recommendations and no instructions for solving problems. To the question “What should I do?” no answer follows, and this is not an omission but a prescription. In 1912, in his “Recommendations to Physicians Practising Psycho-Analysis”, Freud required that the analyst “should be opaque to the analysand and, like a mirror-plate, show nothing other than what is shown to him”.⁷ The rule is called abstinence. Anyone expecting guidance on how to solve his problems expects something that this procedure withholds on grounds of principle.

What psychoanalysis promises to achieve

Anyone considering a treatment of up to three hundred hours reasonably asks one question: what do I have at the end of it?

The question is old, and it has been answered — by Freud himself. In the concluding chapter of the Studies on Hysteria he reports having heard the following objection from his patients repeatedly:

“You tell me yourself that my suffering probably has much to do with my own circumstances and the events of my life; you cannot alter any of that; how then do you propose to help me?”

Freud's reply to it runs:

“I do not doubt that it would be easier for fate than for me to remove your suffering; but you will be convinced that much will have been gained if we succeed in transforming your hysterical misery into common unhappiness.”⁸

This is no sharpening by a critic. It is the goal of the treatment, formulated by the founder, in the founding book of the method.

One may see modesty in it, and one should. Sigmund Freud, unlike some of his successors and unlike some purveyors of present-day methods, never promised the earth. He held human unhappiness to be irremovable, and illness to be the part of it that can be cleared away.

Anyone deciding on a treatment of three hundred hours should have read that sentence. What the psychoanalytic goal of treatment — “transforming hysterical misery into common unhappiness”⁸ — means requires no explaining.

An example

The following account is an anonymized composite of typical cases.

A man in his late thirties comes because the same thing happens to him in every love relationship after about a year. He cannot say what. The women leave him, and each time he understands only afterward that it was foreseeable.

He lies down and talks. Over months no plan and no assignment emerges; a picture emerges. He describes a closeness he creates until it becomes confining, and then a coldness he does not recognize as his own. He describes his mother, who loved him when he was good and fell silent when he was not. He describes how he treats the analyst when she cancels a session.

At some point it strikes him that he does the one thing to forestall the other: he leaves before he can be left. This insight does not arrive as a realization but as a shock.

What is achieved here a short procedure cannot achieve in this way. A recurring relational pattern that the person concerned cannot name is enacted in the relationship with the analyst and there becomes intelligible. That is the domain of the method, and in it the method is strong.

The second question remains open. The man now understands why he leaves. Whether he stays the next time — because he is able, entirely on his own, to identify and correct the self-defeating cognitions within his dysfunctional relational schema — is not thereby settled.

Where is psychoanalysis effective?

Studies of the effectiveness of long-term psychodynamic treatment exist, and they belong here. In 2008 Falk Leichsenring and Sven Rabung presented in the Journal of the American Medical Association a meta-analysis concluding that long-term psychodynamic therapy is effective in complex mental disorders and superior to shorter treatments.⁹

The paper drew four critical letters in the same journal — from Kriston, Hölzel and Härter, from Thombs, Bassel and Jewett, from Roepke and Renneberg, and from Aaron T. Beck and Bhar. A subsequent re-examination of the eight comparative studies found no evidence for the claimed superiority over shorter forms of psychotherapy.¹⁰

The order of magnitude deserves notice: the analysis covered 1,310 patients, of whom 257 received a comparison treatment; eleven of the 23 studies were randomized, the rest merely observational.¹¹

The British database of quality-assessed reviews reached a guarded verdict: the evidence appears to support the authors' conclusions, but the pooling of widely differing results from clinically variable studies means that those conclusions may be unreliable.¹¹

And like psychodynamic psychotherapy, analytical psychotherapy has never in Germany undergone assessment by the criteria of evidence-based medicine. In 2008 the Federal Joint Committee undertook to re-examine the procedures already admitted, and in 2019 it discontinued that undertaking.¹²

In sum: there are indications that long-term psychodynamic treatment works. There is no established evidence that it achieves more than shorter procedures. And for no other procedure is there so wide a gap between the effort authorized and the slender certainty of the statement.

Where it reaches its limits

The first limit is uncontested. In acute psychosis, in acute danger to the self, and in severe acute crisis an analytic treatment is not indicated. It presupposes a resilience that must first be established there.

The second limit lies in the construction of the theory. If a patient contradicts an interpretation, the contradiction can be read as resistance — and resistance counts as confirmation that the interpretation has touched a sore point. Agreement confirms the interpretation as well. A statement confirmed by agreement as much as by rejection cannot be refuted. This is no reproach against individual analysts but a property of the concept.

The third limit is the question of what to do. Psychoanalysis makes intelligible why someone acts as he does. It holds insight to be the effective agent and leaves everything further to the patient — and it withholds recommendation as a matter of principle. Anyone who wants to know what he should change finds no answer in this procedure, and not by accident but by rule.

Cognitive psychotherapy proceeds differently here. It looks for the self-defeating conviction behind the pattern, tests it against reality, and corrects it where it does not hold. Understanding is needed there too — but it is the beginning of the treatment and not its final result.¹³

The difference from psychodynamic psychotherapy

Under the Guideline both belong to the group of psychoanalytically grounded procedures. Three decisions separate them.

The goal. Psychoanalysis aims at a structural change in the personality; psychodynamic psychotherapy at a treatment goal limited in advance.

The stance toward regression. Psychoanalysis encourages the falling back into earlier modes of experience, because the old shows itself in them; psychodynamic psychotherapy restricts it.

The expenditure. Up to 300 hours at up to three sessions a week, lying down, against up to 100 hours at one or two sessions a week, sitting up.⁶

In detail: What is psychodynamic psychotherapy?¹⁴

All the procedures side by side, with insurance status and hour allowances: What forms of psychotherapy are there?¹⁵

Frequently asked questions about psychoanalysis

Does health insurance pay for psychoanalysis?

Yes. In Germany it has been covered by the statutory health insurance system since 1967 under the name analytical psychotherapy.² In Switzerland, since the physician-referral model of 2022, it is not the procedure that decides but the physician's referral.

How long does a psychoanalysis take?

Up to 160 hours are authorized first, and up to 300 at a second step.⁶ At two hours a week that comes to roughly three years. It is the largest hour allowance of all four guideline procedures.

Do you have to lie on the couch?

In analytical psychotherapy, yes; it belongs to the technique and is meant to turn attention inward. Work sitting up is done in psychodynamic psychotherapy.

Will the analyst give me advice?

No, and that is a matter of principle. The rule of abstinence requires the analyst to withhold his own views and recommendations; in 1912 Freud compared him to a mirror-plate.⁷ Anyone seeking guidance on what to do seeks it in this procedure in vain.

What is the difference between psychoanalysis and analytical psychotherapy?

The same procedure is meant. Analytische Psychotherapie is the term used by the German Psychotherapy Guideline; psychoanalysis is the older and more widely used expression.

What did Freud himself name as the goal of the treatment?

To his patients' question of how he proposed to help them, Freud answered that much would be gained if it proved possible to transform their hysterical misery into common unhappiness.⁸ The sentence stands in the concluding chapter of the Studies on Hysteria of 1895.

What is the difference from cognitive psychotherapy?

Both want to understand why someone acts as he does. The difference lies in what happens after the understanding.

Psychoanalysis holds insight itself to be the healing agent and gives no recommendations as a matter of principle.

Cognitive psychotherapy tests whether the conviction behind the pattern holds true at all, and corrects it where it does not. Only this cognitive correction changes the behavior.¹³

Your Comment

Do you have remarks, suggestions, or additions regarding this article? Do you have personal therapy experiences? We welcome substantial feedback.

Website

Name * Email *

Your email address will not be published. It is used solely for potential inquiries by the editors.

Comment *

I agree to the processing of my data in accordance with the Privacy Policy. *

Submit Comment