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What works for you?: A general description of the psychoanalytic approach to psychotherapy

One of the strengths of a practice such as this one is that it consists of six psychotherapists who each have a unique way of thinking about and approaching the work that we do. Psychotherapeutic practice has many many faces, even though there are certain grounding principles which unite the efforts of psychotherapists. But the fact is that even though we all call ourselves psychotherapists, the actual work that we do can be vastly different, and so what happens in each separate space is not only a matter of individual creativity, but also of a choice made by each psychotherapist to follow a particular path based on what we believe to be therapeutically useful. Of course this is directly affected by each person who enters the room, and so the nature and quality of the work done is, in the end of the day, affected by a mutual and reciprocal relationship which develops between therapist and patient. Aside from what happens in the therapist-patient relationship, there is nonetheless the question of "What kind of psychotherapist are you, and does that work for me?" that needs to be thought and talked about when a therapy process begins. With this in mind, and with a view to taking some ownership of the therapy process, I would always encourage people to do a bit of research before entering a process, to explore the forms of therapy that they feel would work for them, and to search for a therapist who engages with these forms of therapy.

The form of therapy that I believe in, and that I offer to the people I work with, is very broadly defined as psychoanalytic psychotherapy. Psychoanalysis, as a form of treatment that has about 150 years of history, is defined in various ways by a number of schools, branching out from classical Freudian thinking. As a method broadly defined, psychoanalytic psychotherapy engages with various levels of depth experience. Firstly, and perhaps most centrally, psychoanalytic psychotherapy concerns the process of drawings links between conscious and unconscious experience; links between the things we know about ourselves, the things we know but don't think about (because it is too painful or anxiety-arousing), and the things we don't know and cannot think about (because it is potentially traumatic). This is why the beginning phase of a psychoanalytic psychotherapy is often focused on asking very detailed and specific questions about history of relationships, family patterns and attachments to the primary people in our lives, as this kind of historical information is an important route to getting to know our unconscious mental life.

Psychoanalytic theory maintains that the vast proportion of mental life is unconscious, meaning that there is much that we don't yet know or understand about the Hows and Whys of our thoughts, feelings and behaviour.  One of the most fascinating and ongoing experiences that we have during the course of a psychoanalytically-oriented psychotherapy is that of discovery, sometimes shocking discovery, as we become acquainted with parts of ourselves which we did not know about. In this sense the psychoanalytic process is one of developing an awareness of - and relationship with - as yet unknown parts of the self, and doing this within the context of a relationship with the therapist, in which there is enough safety and trust for this development to happen; a feature which of course applies to all forms of psychotherapy. For psychoanalytic psychotherapy, however, there is a strong emphasis placed on the dynamics of the therapist-patient relationship. Here we have the second core aspect of the psychoanalytic process: what happens to you, what happens to me, and what happens in between us in the 50-minute hour.

 

The basic principle in psychoanalytic psychotherapy, as far as the relationship is concerned, is that our internal world influences how we relate to people, and so the kinds of relationship conflicts and struggles that take place out there in the world are likely to find their way into the therapy, where they play out in the space between therapist and patient. When this transference of feelings, from the outside in, takes place, we have a unique opportunity to examine and reflect on the known and as-yet-unknown thoughts and feelings taking place in you, me, and us. Often this kind of work can cause a lot of anxiety, especially when there is not enough trust in the therapeutic relationship. This is one of the reasons why psychoanalytic psychotherapy emphasizes the importance of long-term, routine, weekly work, that gives absolute respect to the importance of trust and safety as something that develops over time.

Beyond exploring the ongoing here-and-now dynamics of the therapeutic relationship as a vehicle for developing understandings of the self, psychoanalytic psychotherapy places a very strong emphasis on the notion that therapy mimics and replays the developmental process that we all undergo from infancy to adulthood. The idea here is that the deepest level of psychological injury is that which occurs to us when we are most vulnerable, and least developed. Any form of deprivation, neglect, loss, separation or trauma occurring at this level therefore forms a central part of the therapeutic search, and is considered as an experience which disrupts our development. The work of psychoanalytic psychotherapy is to recognize this level of disruption, and provide the patient with a safe enough relationship which can enable these undeveloped parts of the self to grow.

With considerable emphasis being placed on the notion of developmental trauma, psychoanalytic psychotherapy attends to the various ways in which we defend ourselves against the awareness of too much pain and anxiety. Coming to understand our internal defensive processes, and coming to know how these defensive processes play out in our behaviour, thoughts, feelings and relationships, forms a central part of the focus of the work. With this in mind, and considering the emphasis on psychoanalytic work as a developmental process in itself, it is an important feature of the work that it is not too focused on being directive, and on having a specific plan or structure in mind. The work does not involve any particular step-by-step activities, it is not shaped according to a particular framework other than the absolute boundary of same time, same place, every week. as such, it is a very carefully boundaried, but not particularly directed approach. Often patients struggle with this, and it would be an important aspect of the decision to enter therapy that this aspect is known and understood. And so the question "What works for whom?" is absolutely relevant, and is one that we need to ask before entry into therapy, for the sake of feeling ownership of the process, and knowing that you have arrived at the place you intended to arrive at when you walk into the room. The next big question, and one that I might think about in the next newsletter, relates to the actual fit between the person of the patient, and the person of the therapist.

Being a man in the 21st century – Depression and masculinity

For men of today the pressure is mounting. The call has been sounded for the rising up of a new kind of man, labeled variously as sensitive, new age, emotionally intelligent, in touch with his feminine side, articulate of feelings and emotionally attuned. This shift has been a growing trend in contemporary cultural and social values for a while now, but what exactly does it mean, and how does it translate to the man on the street? The various needs which are pressed upon us as men of a particular kind of world, to adapt and assimilate in relation to a shifting social atmosphere, confuse us from time to time. In some ways the situation of being compelled to catch on to the de rigueur is in itself simple enough to navigate. See what’s out there, see who ascribes to it, and assimilate if it feels authentic for you, if it fits. Toss it away if it doesn’t. When it comes to clothes, music, ideologies, people and places, this seems cut ‘n dried enough. Moving with the times isn’t all that difficult. But what about when it concerns to the self, that mysterious domain of partly known and partly elusive inner experience? What is to be done when the social imperative to rejuvenate calls into question our experience as emotional selves; as emotional men? There is of course no way to generalize about these things. The only truth about the contemporary relationship which men have with their own feelings is that that relationship is formed inside the social, cultural, familial, gender-based and political context which each person comes from. In various ways men have been granted far more permission to think about and communicate their inner emotional experience. We have been extended the invitation to become feelings beings, and we’ve even been told that, amongst other things, this may make us more attractive. Even though this has been a gradual process shaped by the shifts in the social order, it feels somehow as if the movement from being emotionally staunch, invulnerable and unbreakable, to being sensitive, attuned and emotionally switched-on, feels like being  forced out into the open, when we are not quite ready for it.

I write this article as a psychotherapist, who works with a variety of different kinds of people with different kinds of struggles. Some of the work that I do is with men, both individually and in groups, who are trying in their own ways to engage with the quandary of living a life that carries an inherited legacy of the absolute importance of emotional toughness. This legacy weighs heavily on our attempts as men to reestablish ourselves as emotionally liberated. It is the weight that hunched our father’s and grandfather’s shoulders, as they spent their lives staunching the flow of feeling, for the sake of living up to the social imperative to soldier on. We are faced with a duality of voices, which ask us to soften, but order us to nut up. Voices which invite us to collapse a little, but order us to be a man. The link between standards of masculinity and emotionality has been set in stone, and the consequence, as it seems, is that men continue to be bound by the old adage “boys don’t cry”, even though no one really says that anymore, hopefully.

Considering this struggle, it seems that men are still confronted with a situation of being limited in our opportunities for emotional experience and expression. The space for feeling is still a confinement, with there being few possibilities for talking about and demonstrating what we feel and how we feel it. One of the ways in which this comes through most strongly seems to relate to the language that we are allowed to use when talking about our internal worlds. The language of feeling for men, bound as it is to standards of masculinity, is one of limited vocabulary. We have certain words which we can use as often as we like. We can say of ourselves that we are stressed, that we are angry, tired, ticked off. We can acknowledge when we are struggling to asleep, but when it is feelings of sadness of loneliness that keep us up at night, we may feel the need to hide this. We can say that we need to blow off some steam. We can even, on occasion say that we’re not happy with our lives, that we are discontent or dissatisfied with the way things are. But can we ever be vulnerable? Can we express feeling overwhelmed? Is it possible for us to freely and safely say that we feel fragile or frightened, or that we are lost? Oftentimes it’s not possible, and the consequence is that much of our inner experience goes unsaid, unrecognized and unattended to. One of the implications of this, as it seems, is a pervasive, low-level experience of depression, as our emotional experience continues to be locked away, and we continue to try and cope with an unsatisfying and stilted emotional and interpersonal life.

It is a hopeful sign that men are finding it more and more acceptable to work through their struggles in therapy, and I have often found that such work can be deeply facilitative of the kind of growth towards emotional liberation which this article talks about. The struggle still exists out there in the world, where men struggle to feel able to experience and express feeling, either because of their own self-imposed sanctions, or because of their expectations of judgement by others. Either way, there is room for a much needed change and growth.