Psychoanalytic psychotherapy

Psychoanalytic psychotherapy may be characterized by the same basic techniques as psychoanalysis, but with quantitative modifications that, in combination, result in a qualitative shift in the nature of the treatment. Any given session of psychoanalytic psychotherapy may be indistinguishable from a psychoanalytic session, but over time, the differences emerge quite clearly. Psychoanalytic psychotherapy utilizes interpretation, but with patients with severe psychopathology, a good deal of time must be devoted to clarification and confrontation before interpretation can be effective; and interpretations of unconscious meanings in the 'here and now'

occupy the foreground until late in the treatment, when genetic interpretations in the 'there and then' become useful. (j 34)

In the treatment of patients with severe character pathology, transference analysis is the essential focus of psychoanalytic psychotherapy from the very beginning; it must be modified, however, by active interpretive connection of transference analysis with exploration in depth of the patient's daily life situation, an approach made necessary by the predominance of primitive defence operations in these patients. Splitting operations in particular tend to dissociate the therapeutic situation from the patient's external life, and may lead to severe, dissociated acting out either in the sessions or outside the sessions. Therefore, interpretive linkage between the patient's external reality and transference developments in the hour becomes central.

In order to enable the therapist to analyse transference developments in sufficient depth, psychoanalytic psychotherapy requires a minimum frequency of two sessions per week. It is usually carried out in 'face-to-face' sessions.

Technical neutrality is an essential feature of analysis in general, but in the treatment of patients with severe character pathology the need to set limits may necessitate repeatedly abandoning neutrality, in order to control life-threatening or treatment-threatening acting out. The self-perpetuating nature of acting out in these cases may prove impossible to resolve interpretively without such structuring or setting limits. Whenever the analyst has to abandon technical neutrality to protect the patient or the treatment, it is essential to explore the episode immediately. The transference implications of the therapist's structuring behaviour must be laid out, followed by the analysis of the transference implications of the patient's behaviour that necessitated the imposition of limits or the initiation of a new structure in the treatment; this in turn is followed by the gradual resolution of the structure or limit setting by interpretive means, thus restoring technical neutrality. In short, technical neutrality in psychoanalytic psychotherapy is an ideal working state that is again and again preventively abandoned and interpretively reinstated. (j 3 36)

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