Long-Term Treatment in Modern Psychoanalysis
Psychoanalysis is often criticized for taking too long, and for being far too costly when the money paid over all those years in treatment is added up. This brief writing contains just a few thoughts on the uses and resistances involved in thinking about long-term treatment.
The average time of those staying in psychoanalytic treatment in the United States is estimated to be somewhere over 5 years. Yet, when our patients first come to see us, it is unlikely that many plan on staying in treatment for over 5 years; let alone for the 10 or 20 years that some do.
As Dr. Hyman Spotnitz notes: (1985, pp. 112-13)
When contemplating treatment… pathologically narcissistic individuals are rarely interested in change. What they want primarily – and immediately – is relief from emotional suffering. They are more likely to feel that they would be investing time, money, and effort just to prove they are incurable.
So, how long is too long to be in analysis – how much time and money should one spend addressing life-long difficulties? Perhaps our views about therapy before we enter it would help with the answer.
Arnold Bernstein (1995, p. 52) contends that:
The expectations of both the therapist and the patient are derived from their preconceptions of what psychotherapy is, and of what it means to be cured. Foremost among these preconceptions is that the patient is ’sick’ and that the treatment is to be regarded as medical in nature.
Prior to entering treatment, patients can entertain a variety of other ideas about what treatment means and what might happen during the treatment. (See e.g., Strean, 1985, pp. 110-112).
Modern psychoanalysts generally try to create an analytic space or “holding environment” where it is safe for the patient to “say everything.” In this context, resistance most often refers to whatever interferes with saying everything (talking) and the modern analyst works at whatever level the patient is at.
Thus, a patient with difficulties which may have developed in the pre-verbal (or pre-oedipal) stage of maturation might be helped to develop a narcissistic transference before moving further.
According to Spotnitz, (1985, p. 121), in most cases 2 years would be “… the minimum duration for significant change to occur” and “(a)lthough the effective reversal of the schizophrenic reaction requires a minimum period of 5 years, the treatment may continue for a longer period.”
Freud (1913, p. 130) similarly stated “(t)o shorten analytic treatment is a justifiable wish… unfortunately, it is opposed by a very important factor… the slowness with which deep-going changes in the mind are accomplished.” We can certainly see the point where serious difficulties, such as schizophrenia, are concerned.
However, our minds often reject the idea of creating such intense long-term emotional attachments to strangers.
However, our minds often reject the idea of creating such intense long-term emotional attachments to strangers.
As Bernstein (1995, p. 51) says:
A prolonged therapeutic relationship is more likely to be a source of embarrassment… than a cause for rejoicing. Quite the contrary is the case when other personal human relationships come to an end. When marriages, families, friendships and loveships break up, it is generally conceded that something went wrong.
So it may horrify one, looking at it from the outside - to hear of an individual spending many thousands of dollars over 5, 10 or 20 years in analysis - but, if it helps that individual achieve a real and meaningful life, was it all worth it? Only that person can say.
In the end, perhaps its all a question of value and connection. How do we view our attachments, ourselves, and our value as human beings? What are those things worth?
References
Bernstein, A. (1995). Some Clinical Observations Upon the Emergence of the ‘Wonder Child” (CMPS/Modern Psychoanalysis, Vol. XX, No. 1, 1995).
Freud, S. (1913). On Beginning the Treatment. Standard Edition. London, Hogarth Press, 12:121-144.
Spotnitz, H. (1985). Modern Psychoanalysis of the Schizophrenic Patient: Theory of the Technique, Second Edition, NY, Human Sciences Press.
Strean, H. (1985). Resolving Resistances in Psychotherapy, NY, Wiley.
