Psychoanalytic treatment is based on the idea that people are frequently motivated by unrecognized or unconscious wishes and desires, as well as fears and anxieties. These desires and fears are often set up in early childhood and tend to persevere as relationship issues in adulthood or persistent personality traits. Moods, substance abuse, repetitive failures, traumatic reactions, and severe anxieties all may have a basis in these early traumas. In adult life, these patterns tend to repeat in actions but out of conscious awareness.

These can be identified through the relationship between the patient and the analyst. By listening to patients’ stories, fantasies, and dreams and discerning how patients interact with others, psychoanalysts offer a unique perspective that friends and relatives might be unable to see. The analyst also listens to how these patterns occur between the patient and the analyst. What is out of the patient’s awareness is called “transference,” and what is out of the analyst’s awareness is called “countertransference.” The psychoanalyst is trained to understand these transference patterns and find ways to communicate these patterns in the treatment. The psychoanalyst also uses his or her emotional reactions as a guide to what his or her patient might be feeling and as an empathic way of relating.

Talking with a trained psychoanalyst helps identify underlying patterns and behaviors. By analyzing the transference and countertransference, the analyst and patient can discover paths toward the emotional freedom necessary to make substantive, lasting changes and heal from past traumas.

Typically, psychoanalysis involves the patient coming three to five times a week and communicating as openly and freely as possible. While more frequent sessions deepen and intensify the treatment, the frequency of sessions is worked out between the patient and analyst. The length of treatment can vary but typically is several years or more.

In psychodynamic psychotherapy, the primary difference is that the patient and analyst meet less frequently, sometimes only once a week. As with psychoanalysis, the frequency of sessions can be customized to the patient’s needs. Another difference is that the patient usually sits upright and opposite the therapist rather than reclining on a couch with the therapist out of view.

Other than these differences, psychoanalytic psychotherapy is very much like analysis in its use of free association, the importance placed on the unconscious, and the centrality of the patient-therapist relationship.

With the onset of COVID-19, psychoanalysts have been experimenting with virtual sessions. While there is no consensus on its effectiveness, many patients find these sessions helpful.

Transference is a concept that refers to our natural tendency to respond to certain situations in unique, predetermined ways – predetermined by much earlier, formative experiences, usually within the context of the primary attachment relationship. These patterns, deeply ingrained, arise sometimes unexpectedly and unhelpfully – in psychoanalysis, we would say that old reactions constitute the core of a person’s problem and that he or she needs to understand them well to be able to make more useful choices. Transference is what is transferred to new situations from previous situations.

As a result, a person’s relationship to lovers and friends and any other relationship, including his psychoanalyst, includes elements from his or her earliest relationships. Freud coined the word “transference” to refer to this ubiquitous psychological phenomenon, and it remains one of the most powerful explanatory tools in psychoanalysis today – both in the clinical setting and when psychoanalysts use their theory to explain human behavior.

Transference describes the tendency for a person to base some perceptions and expectations in present-day relationships on his or her earlier attachments, especially to parents, siblings, and significant others. Because of transference, we do not see others entirely objectively; rather, we “transfer” onto them the qualities of other important figures from our earlier lives. Thus, transference leads to distortions in interpersonal relationships and nuances of intensity and fantasy.

The psychoanalytic treatment setting is designed to magnify transference phenomena so that they can be examined and untangled from present-day relationships. In a sense, the psychoanalyst and patient create a relationship where all the patient’s transference experiences are brought into the psychoanalytic setting and can be understood. These experiences can range from a fear of abandonment to anger at not being given to fear of being smothered and feelings of

As uncomfortable thoughts and feelings begin to get close to the surface – that is, become conscious – a patient will automatically resist the self-exploration that would bring them fully into the open because of the discomfort associated with these powerful emotional states that are not registered as memories, but experienced as fully contemporary – transferences. The patient is thus experiencing life at too great an intensity because he or she is burdened by transferences or painful emotions derived from another source and must use various defenses (resistances) to avoid their full emotional intensity.

These resistances can take the form of suddenly changing the topic, falling into silence, or trying to discontinue the treatment altogether. To the analyst, such behaviors would

signal the possibility that a patient is unconsciously trying to avoid threatening thoughts and feelings, and the analyst would then encourage the patient to consider what these thoughts and feelings might be and how they continue to exert an important influence on the patient’s psychological life.

As the analysis progresses, patients may feel less threatened and more capable of facing the painful things that first led them to the analysis. In other words, they may begin to overcome their resistance.

Psychoanalysts consider resistance to be one of their most powerful tools, as it acts like a metal detector, signaling the presence of buried material.

Trauma is a severe shock to the system. Sometimes, the system that’s shocked is physical, such as a bodily injury. Sometimes, the system is psychic, such as a deep emotional blow or wound (which itself might be connected to a physical trauma). Psychoanalysis can attempt to counteract the aftereffects of psychical trauma.

While many emotional wounds take a while to resolve, psychic trauma may continue to linger. When the stimulus is powerful enough – a death, for instance, or an accident – the psyche isn’t able to respond sufficiently through regular emotional channels such as mourning or anger.

Often, this lack of resolution can foster a repetition compulsion – a chronic re-visiting of the trauma through rumination or dreams or an impulse to place oneself in other traumatic situations. Psychoanalysis can help the victim to develop emotional and behavioral strategies to deal with the trauma.

Fortunately, the need for trauma survivors to have treatment is now well understood in the broader mental health community. Certain medications are helpful in the treatment of trauma. Still, there should always be a psychological component to the treatment, and it must be understood that treatment can be needed years after the trauma is experienced.

Psychoanalysts did much of the early work in treating trauma, from shell shock of WWI, War Neurosis of WWII, Post-Vietnam Syndrome of the Vietnam War, and now Post Traumatic Stress Disorder (PTSD). Treatment of PTSD still contains elements that harken back to psychoanalysis – trauma patients need a witness to their pain who helps them, bit by bit, incorporate the traumatic experience with the rest of the story of their lives in some way that can make sense. Facing unbearable feelings with another human being, and supporting and employing the ego- the part of the mind responsible for decision making, understanding cause and effect, and discrimination – all these techniques owe their roots to psychoanalysis.

Another common tendency in adult life is to project. We tend to be unaware of internal conflicts and see them in others. It is very hard to be aware of what one is projecting. For example, I do not feel angry at you, but I think you are angry with me. Projection is ubiquitous and is evident in any close relationship of partners, friends, and co-workers. However, projection can interfere with relationships and cause angry disruptions when pronounced. Because patients will project toward their analysts, these difficulties can be directly identified and discussed.

Links to videos about psychoanalysis

What is psychoanalysis? American Psychoanalytic Association

What is psychoanalysis? Toronto Psychoanalytic Institute

Introduction to psychoanalysis, Professor Otto Kernberg

The psychodynamic diagnostic process, Nancy McWilliams

The difficult patient, Dr. Glenn Gabbard