Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 28: Psychotherapies

Table 28.1-1 Scope of Psychoanalytic Practice: A Clinical Continuum a

Psychoanalytic Psychotherapy

Feature

Psychoanalysis

Expressive Mode

Supportive Mode

Frequency

Regular four to five times per week; “50-minute hour”

Regular one to three times per week; half to full hour

Flexible one time per wk or less; or as needed half to full hour Short or intermittent long term; single session to lifetime Patient and therapist face to face; couch contraindicated Formation of therapeutic alliance and real object relationship; analysis of transference contraindicated with rare exceptions; focus on conscious external events; regression discouraged Neutrality suspended; limited explicit gratification, direction, and disclosure Auxiliary or surrogate ego as temporary substitute; holding environment; insight to degree possible Severe character disorders, latent or manifest psychoses, acute crises, physical illness Some degree of motivation and ability to form therapeutic alliance Reintegration of self and ability to cope; stabilization or restoration of preexisting equilibrium; strengthening of defenses; better adjustment or acceptance of pathology; symptom relief and environmental restructuring as primary goals Free association method contraindicated; suggestion (advise) predominates; abreaction useful; confrontation, clarification, and interpretation in the here-and-now secondary; genetic interpretation contraindicated Often necessary (e.g., psychotropic drugs, family rehabilitative therapy, or hospitalization); if applied, its positive implications are emphasized

Long-term; usually 3 to 5 + years Short or long term; several sessions to months or years

Duration

Setting

Patient primarily on couch with analyst out of view Systematic analysis of all positive and negative transference and resistance;

Patient and therapist face to face; occasional use of couch Partial analysis of dynamics and defenses; focus on current

Modus

operandi

interpersonal events and transference to others outside of sessions; analysis of negative transference; positive transference left unexplored unless impedes progress; limited regression encouraged Modified neutrality; implicit gratification of patient and greater activity Insight within more empathic environment; identification with benevolent object Neuroses; mild to moderate character psychopathology, especially narcissistic and borderline disorders Moderate to high motivation and psychological mindedness; ability to form therapeutic alliance; some frustration tolerance Partial reorganization of personality and defenses; resolution of preconscious and conscious derivatives of conflicts; insight into current interpersonal events; improved object relations; symptom relief a goal or prelude to further exploration Limited free association; confrontation, clarification, and partial interpretation predominate, with emphasis on here- and-now interpretation and limited genetic interpretation

primary focus on analyst and intrasession events; transference neurosis facilitated; regression encouraged

Analyst/

Absolute neutrality; frustration of patient; reflector/mirror role Insight predominates within relatively deprived environment

therapist role

Mutative change agents

Patient

Neuroses; mild character psychopathology

population

Patient

High motivation, psychological mindedness; good previous object relationships; ability

requisites

to maintain transference neurosis; good frustration tolerance

Basic goals

Structural reorganization of personality; resolution of unconscious conflicts; insight into intrapsychic events; symptom relief an indirect result Free association method predominates; full dynamic interpretation (including confrontation, clarification, and working through), with emphasis on genetic reconstruction Primarily avoided; if applied, all negative and positive meanings and implications are thoroughly analyzed

Major

techniques

Adjunct

May be necessary (e.g., psychotropic drugs as temporary measure); if applied, its negative implications explored and diffused

treatment

a This division is not categorical; all practice resides on a clinical continuum.

60s or 70s. One final contraindication is a close relationship with the analyst. Analysts should avoid analyzing friends, relatives, or persons with whom they have other involvements.

Ms. M, a 29-year-old unmarried woman who worked in a low- level capacity for a magazine, presented for consultation with the chief complaints of considerable sadness and distress over her parent’s reaction when they found that she had had a homosexual relationship. She also realized that she had been working far below her potential. She had never sought any treatment before. She was clearly intelligent, sensitive, self-reflective, and insightful. When

Patient Requisites The most important patient requisites for psychoanalysis are listed in Table 28.1-3.