Psychoanalytic therapy. Basic principles of psychoanalysis

Psychoanalysis

There is a paradox: many people who need psychological help are looking for psychoanalysis but few are willing to go real psychoanalysis. This is due to ignorance of the features of psychoanalysis.

Freud did psychoanalysis 6 times a week. After the transition in Europe to a five-day work week, five sessions per week became the standard for psychoanalysis. A very limited number of patients are ready for this, so in the USA they compromised, allowing it to be considered real psychoanalysis if the patient visits a psychoanalyst 4 times a week. The French turned out to be even more "compliant" and "allowed" their patients to visit a psychoanalyst only three times a week, calling it also psychoanalysis.

In Freud's time in a small, by modern standards, Vienna at the beginning of the 20th century, it was possible and even desirable for non-working wives of wealthy burghers, who, basically, were Freud's patients, to visit their psychoanalyst 6 times a week. Moreover, the analyzes at that time were very short, no longer than three months (with rare exceptions). This time turned out to be sufficient, as Freud put it, in order to make an unhappy person out of a neurotic . But three months turned out to be insufficient for the recovering neurotic to adapt to the reality around him, from which, in fact, he "hid" in a neurosis. Therefore, some of Freud's well-known patients were subsequently treated by other psychoanalysts for a long time.

In this regard, modern psychoanalysis lasts from several years to ten years or more. Today in large cities, with their vast distances, people who spend more than nine hours a day at work do not have the opportunity to visit a psychoanalyst so often. And most people are not able to pay the fees of psychoanalysts for 5 sessions a week. In part, the requirement for such a high frequency of visits crisis of psychoanalysis, which began in the 50s of the XX century (I described other components of this crisis in the article).

Psychoanalytic psychotherapy

Freud predicted, that the mass application of our therapy will compel us to fuse the pure gold of analysis with copper ...» So Freud foresaw the appearance psychoanalytic psychotherapy.

Thanks to more relaxed requirements for the frequency of visits psychoanalytic psychotherapy was more in demand. A patient of a psychoanalytic psychotherapist can attend psychoanalytic sessions 1-2 times a week, and will not be persuaded to go to 3-4 times a week, which is most often done. real psychoanalysts, believing that only such a high frequency of visits can give a good result.

I must confess that I, too, find a greater frequency of visits preferable to infrequent visits. With more frequent visits to the patient, psychotherapeutic work is deeper and more effective (hence I suggest more to encourage patients to walk more often). But I am aware that not all of my patients can afford it.

Usually, at the beginning of psychoanalytic psychotherapy, patients have a high need for psychoanalytic sessions, and if possible, they go often. As a result of psychotherapeutic work, such a need, as a rule, decreases, and the frequency of visits gradually decreases, down to, sometimes, up to 1 time per month. Most importantly, I can accompany and support my patients for a long period of their life path, without replacing their personal lives with psychoanalytic sessions, and they won't.

It happens that a patient comes to me and says that he has a deferred amount that allows him to attend my sessions, for example, 3 times a week for a year. And there are no more savings, and with his income, he cannot continue psychoanalysis for a longer time. In this case, I say that it is better to go 3 times a week for 3 years than 3 times a week for 1 year.

The human psyche is very inert: a child is able to learn to walk confidently only by about 5 years, to speak confidently - to 10, to write - to 15. Neurosis is always formed in childhood, and, in fact, always turns out to be chronic, (if we are not talking about child psychoanalysis). Therefore, the duration of psychoanalytic psychotherapy is prioritized over the frequency of visits to the patient.

These words should not be understood in such a way that the patient should go to a psychoanalyst for, say, three years, and only in the third year, finally, be cured of neurosis or depression. On the contrary, the first positive changes may appear in a few months even with a visit once a week - but it takes years for a sustainable result.

But such long-term psychotherapeutic work is not always needed. There is also the so-called focus psychoanalytic psychotherapy which usually lasts only a few months. The peculiarity of such psychotherapy is that the analysis focuses on one issue. Such psychotherapy is not suitable for the treatment of neurosis or depression, but helps to alleviate the affective state associated with mental trauma, for example, caused by divorce.

Psychoanalytic and psychotherapeutic factors

Freud emphasized that he developed psychoanalysis as method of exploring the unconscious , and he considered the therapeutic effect of psychoanalysis only by-product such research.

In psychoanalysis, it is customary to distinguish psychoanalytic And psychotherapeutic factors. The psychoanalytic factor is the exploration of the unconscious ( "pure gold" of psychoanalysis ). And psychotherapeutic factors aim to alleviate the patient's condition, primarily through support ( "impurities" to psychoanalysis ). predominance supporting interpretations (psychotherapeutic factor) regarding expressive insight-oriented (psychoanalytic factor) is a characteristic feature of psychoanalytic psychotherapy that distinguishes it from psychoanalysis. Therefore, psychoanalytic psychotherapy is also called.

Very few patients are willing to receive only "pure gold" of psychoanalysis . So psychoanalyst Frederick Perls escaped from and founded a new kind of psychotherapy with big amount"impurities", gestalt psychotherapy.

Interestingly, judging by the historical facts, Freud was very kind to patients and could build trusting close and deep relationships with patients. That is, Freud himself had already used " impurities"to psychoanalysis, without which there can be no therapeutic effect.

Another distinctive feature of real psychoanalysis, oriented towards the study of the unconscious, is providing space for the patient to explore his unconscious. It is believed that if the psychoanalyst speaks less, this will enable the patient to independently analyze his unconscious, i.e. work analytically . In support-oriented psychoanalytic psychotherapy, much more activity of the psychotherapist is allowed if the patient needs it. For example, for depressed patients silent psychoanalyst turns out " dead mother "(André Green), resulting in iatrogenic retraumatization of the patient.

Judging by the records of psychoanalytic sessions that have come down to us, Freud was not a particularly silent psychoanalyst. However, silence of psychoanalysts became the talk of the town. But when the psychoanalyst is silent, the patient lying on the couch, not seeing the psychoanalyst, may fear that the psychoanalyst.

On the couch or face to face

Freud initially needed a couch to treat his patients, because. he used hypnosis while practicing, discovered by his psychiatrist teacher Joseph Breuer. Then, disillusioned with hypnosis (see), Freud kept the couch because, as he put it, he doesn't want to be looked at .

The couch, of course, has great advantages: the patient is in a relaxed state, can close his eyes and delve into his thoughts, memories and experiences. Patients very rarely fall asleep on the couch, but still, the lying position is closer to sleep and waking "dreams" (fantasies). And as Freud said, dreams are the royal road to the knowledge of the unconscious .

Since the psychoanalyst sits at the head of the couch and the patient cannot see him, this position makes it easier for the patient to say whatever comes to mind (free associations) – basic rule of psychoanalysis. This makes it especially easy to say what the patient thinks of the psychoanalyst himself - an analysis of the patient's feelings towards his psychoanalyst is specific feature psychoanalysis, and is called. After all, what is difficult to say in the eyes is easier to say, looking at the ceiling.

Psychoanalytic psychotherapy was born in the depths of psychoanalysis, but the technical principles of psychoanalysis developed by Sigmund Freud cannot be "simply" transferred to psychoanalytic psychotherapy - that is quite another clinical interaction. Therefore, the training of a psychoanalytic psychotherapist requires special education.

1960s By this time, it became clear that psychoanalysis as a method of therapy is not suitable for everyone who needs psychological help. Psychoanalysis takes a long time and requires large financial outlays; its purpose is not to cure a certain symptom, but to uncover the underlying causes of its occurrence. The development of psychoanalytic psychotherapy begins. Both of these psychotherapeutic practices are based on an analytical approach to the human psyche and its disorders. The difference between them is that in therapy the emphasis is not on the exploration of the psyche, but on the resolution of specific behavioral and psychological difficulties that the patient faces. Today, psychoanalytic psychotherapy is a common practice that allows patients to achieve tangible improvements in a relatively short time.

Definition

Psychoanalytic psychotherapy is often referred to as a lightweight version of psychoanalysis. The objectives of this type of therapy are as close as possible to the goal: to help the patient become aware of his unconscious conflicts - the causes of his behavioral and emotional difficulties. To achieve this goal, the psychotherapist listens to the patient (by the method of free association) and interprets unconscious contents. However, unlike psychoanalysis, psychoanalytic therapy places more emphasis on supporting the patient.

Operating principle

Psychotherapy, in its broadest sense, is a set of psychological actions aimed, firstly, at eliminating painful symptoms, and secondly, at the patient's personal growth. To achieve these goals, representatives of various therapeutic schools use different techniques and methods. Psychoanalytic therapy, like psychoanalysis, refers to the unconscious, believing that it plays a leading role in the formation of symptoms, disturbances in adaptation or in the patient's personal relationships. However, this direction has many differences from psychoanalysis. The patient does not lie on the couch, the session takes place "face to face" - the therapist thereby emphasizes a benevolent attitude towards the patient (in contrast to the neutrality of the psychoanalyst). Psychoanalytic psychotherapy, like psychoanalysis, is a “treatment with words”: the patient tells the therapist everything that comes to his mind, and thereby gives vent to his painful emotions, experiences and fantasies. Talking about past traumatic experiences has a therapeutic effect in itself. On the part of the therapist, it is reinforced by the interpretation (help in understanding) the patient's unconscious conflicts, as well as his non-critical, friendly attitude and support, which allows the patient to gain a new experience of communicating with another person.

Progress

The first 3-4 meetings are devoted, as a rule, to clarifying the complaints with which the person came to psychotherapy. The result of these meetings is the joint formulation of goals that the therapist and the patient can achieve as a result of work. After the conclusion of the therapeutic contract, the psychoanalytic psychotherapist, as it were, fades into the background, giving more space to the patient and encouraging him to express as fully as possible everything that comes to his mind. Gradually, the patient learns to freely express his thoughts and feelings, doubts, questions to himself, mentions his dreams and fantasies. The therapist, listening to the patient, focuses on his unconscious, trying to find in it the causes of his suffering or difficulties. Psychological transference also becomes an object of interpretation, as in psychoanalysis. This helps to see, right in the session, how the patient's past relationship is reproduced in his current relationship with the therapist.

Indications for use

Psychoanalytic psychotherapy is effective not only for neurosis, depression, phobias or personality disorders (like psychoanalysis). Her technique has also been adapted for the treatment of more severe disorders - psychoses and psychosomatic diseases (in these cases, the psychotherapist, as a rule, works in tandem with a psychiatrist or general practitioner). In addition, a new direction has been actively developing recently - psychoanalytic couples therapy.

How long? What is the price?

The duration of the course of psycho-analytic psychotherapy is shorter than that of psychoanalysis: from several months (short-term therapy) to 3-4 years. Meetings take place once or twice a week; their frequency depends on psychological state the person who asked for help, and from his material capabilities. The spread in prices depends on the experience and qualifications of the psychotherapist and ranges from 1,700 to 3,000 rubles per session (1 hour).

During the last decade there has been a steady increase in interest in psychotherapy. Despite the fact that pharmacological agents remain the main method of helping the mentally ill, psychotherapy is being integrated into medicine as a necessary component of the rehabilitation of a psychiatric patient. Describing the problems of providing psychotherapeutic assistance in the West, I. Yalom (4) writes: “It seems that the current generation of psychiatrists-clinicians, who are versed in both dynamic psychotherapy and pharmacological treatment, is dying out as a species.” Based on our own observations, it can be argued that in the Russian psychiatric community the picture is rather the opposite - interest in psychotherapy and, in particular, psychoanalysis is growing.

However, the number of such specialists is still scanty, which is due to a number of reasons: the duration and significant material costs of training, the few psychotherapists who could act as mentors (supervisors, training analysts), etc. The personal experience of using psychotherapeutic approaches in the practice of a psychiatrist proves that that this resource is extremely useful. This article is devoted to the application of the techniques of modern psychoanalysis in the routine practice of a doctor in a psychiatric day hospital (DS).

Some theoretical aspects of modern psychoanalysis

The essence of the concept of schizophrenia in modern psychoanalysis in an extremely schematic form can be represented as follows: mental disorders are the result of the patient using a psychologically unsuccessful defense against his own destructive behavior (3). The main symptoms of the disease (autism, apathy, emotional dullness) reduce the ability to interact with the outside world, preventing narcissistic rage from manifesting (1). In this case, the destruction of the mental apparatus of the subject - the ego of the patient occurs. These processes affect the early development of the child (preverbal period). That is, each schizophrenic patient has a large store of repressed aggression and behavior aimed at minimizing his interaction with others, which protects him from the release of uncontrolled aggression. Given the preverbal nature of the disorders, high levels of anxiety and a tendency to deep regression, the psychoanalyst must be given a safe space to develop verbal activity and develop the ability to establish relationships with the outside world (analyst, loved ones, society, etc.).

On the way to the patient's recovery, there are many obstacles (resistances), which can be grouped into several types. Firstly, it is resistance to destructive treatment, when the patient consciously and unconsciously seeks to interrupt therapy. Secondly, resistance to the status quo - the tendency not to change (“I don’t want anything new”, “no new thoughts”, “everything is fine”). Thirdly, resistance to cooperation: social contacts do not appear in the patient's life or they are unsuccessful. The last type of resistance is towards the end of treatment. The analyst becomes such an important figure in the client's life that parting with him seems like a disaster. The resolution of these resistances requires special techniques.

In modern psychoanalysis, the situation when the patient says everything (free associations) is avoided. this contributes to the fragmentation of the ego and further regression, that is, increases the psychotic symptomatology. The client speaks on topics of interest to him, which allows him to regulate the importance of information and the level of anxiety. The preverbal patient is able to evoke strong feelings in the analytic (countertransference), which are explored and used in communication (see below, Intervention 4.8). In modern analysis, interpretations are not used to resolve resistance, but alternative forms of verbal communication are effective - attachment, mirroring (Interventions 1-3, etc.). Questions or comments directed at the patient's ego, so-called ego-oriented interventions, are not are usually taken as an attack and cause regression ( You wet? What You ate for breakfast?). If possible, they are replaced by similar object-oriented statements, where attention is shifted to the object world, without affecting the ego of the patient (Rain managed to wet your clothes? A What Was it for breakfast? The use of these or other techniques is determined by the degree of impairment of the patient: with a deep regression, he needs a direct recommendation on how to cook his own food or what needs to be done to avoid pressing problems. At a lower level of disorders, attachment, mirroring is used. If there is a good level of compensation - interpretation. That is, everything that can help the patient overcome resistance is used in the work of the modern analyst.

Psychoanalytic techniques in psychiatric practice

We can say that in psychiatry we are faced with the same resistance of patients as in modern psychoanalysis. Probably the most important of these, and of direct relevance to practice, is the resistance to destructive treatment, since most patients (especially primary or paranoid ones) are unwilling to receive medical help. In a simplified form, this can be explained by the fact that the surrounding world, including the doctor, does not share the views of a suffering person who is “pursued” by neighbors, the state or mystical forces. Instead of offering protection, he is offered even more control (psychiatric hospital and taking "harmful" drugs).

Attachment and mirroring are the most important techniques in working with such patients. Attachment - Interventions that maintain or increase existing resistance until the patient develops sufficient awareness. In mirroring, the therapist behaves as a mirror image of the client's behavior, thoughts, or feelings. These techniques seem to bridge the gap between the patient and the doctor, helping the patient to feel that he is not alone, that his point of view is accepted by others. The separation of these views prevents the patient's Ego from further disintegration, "slipping" into psychosis.

The author's considerations about the possible mechanisms of the interventions listed below are a personal point of view based on the theoretical basis of modern psychoanalysis, and, of course, do not exclude other ways of interpretation. An attempt is made to look into the psychological mechanisms of psychopathology and its correction. It can be hoped that in the future, the term "psychologization" will acquire a positive character in psychiatry, expanding not only the understanding of pathogenesis, but also the scope of possible assistance.

Clinical examples of the use of techniques

Usually paranoid patients do not want to receive psychiatric help and attempts to persuade them on a rational level often do not work. However, the offer to deal with what is happening “really” (UFO influence, gang persecution or mystical influence) meets with agreement, and they are more willing to cooperate. The need to obtain the consent of the patient for treatment in the DS is a professional task, because. examination and therapy can only be voluntary under these conditions.

Intervention 1.

An elderly woman with manifestations of a hallucinatory-paranoid syndrome is referred to the DC, but she does not see the point in visiting him.

Patient: I don't know what's going on, but medicine won't help.

Doctor: Why?

P: It's kind of mystical.

Q: We will help you deal with it.

P: Do you have specialists in sorcerers?

Q: We have the best specialists in sorcerers.

P: My sorcerer is so strong that you, the wrong one, will not be able to cope.

V: Nothing, we are also not born with a bast ...

The patient is encouraged and begins to briskly talk about the intrigues of the "sorcerer" who lives between the floors and constantly "influences" her. Receiving support and understanding, he agrees to accept medical assistance. In a similar situation of admission to the DS:

intervention 2.

Q: How about treatment with us?

P: I'm not crazy, what should I do with you? This demon is bugging me.

Q: Yes, of course, a demon. But it can only affect the weak nervous system. He destroys it, and you become his easy prey.

P: Well, what can I do about it?

Q: You are not. Doctors - yes. We will prescribe medicines that will strengthen your nerves and then the demon will no longer be able to mock you and will fall behind you.

P: I don't mind restoring my nerves. Well let's try.

For those who have already agreed to treatment, there are problems with establishing contact and prescribing medication. The patient is a 25-year-old man, diagnosed with schizotypal disorder. Mental disorders for six years: the phenomenon of depersonalization, fear of social failure, anxiety, aggressive fantasies, paranoid experiences, suicide attempt. He was treated inpatiently and received neuroleptics and antidepressants on an outpatient basis, no significant effect was noted. He briefly received therapy from a psychotherapist of a humanistic direction, with a conflict he stopped therapy. The analyst who started working with the patient noted his aggressive tendencies and disagreed with the existing medication (antidepressants). Sent to the DS for the selection of therapy. From the very beginning, he was not interested in treatment. He agreed to see a doctor, as his psychoanalyst insisted on it. During the conversation, actual paranoid experiences came to light. The doctor changes the nature of the conversation - he chooses joining techniques, and then joining with amplification.

intervention 3.

P: … I have one more thought. It concerns the president. I don't even know if I should talk about it.

Q: What about the president?

P: I think there should be two.

Q: Man and woman?

P: Exactly! Husband and wife. Don't you think I'm talking nonsense?

Q: It seems to me that there should be three of them.

P: That is?

Q: A whole family - husband, wife and child.

P: I think so too, but I was afraid to speak. I thought you wouldn't understand.

Q: Maybe there should be four of them?

P: Two children of different sexes?

B: No, it's also a pet, like a cat.

P: No, this is nonsense ... Well, if there was a dog ... well, no, this is some kind of nonsense with an animal.

At the end of the dialogue, the doctor reinforces the connection, introducing a significant amount of absurdity. Thus, the patient's ideas about the presidency come into conflict with the absurd, but essentially similar statement of the psychiatrist. The result of the intervention was that the patient was able to talk more about his experiences and agreed with the correction of therapy.

On another occasion, the same patient began to insistently ask his psychiatrist to conduct "psychotherapy" with him, because. his psychoanalyst will be able to see him only after a week.

intervention 4.

P: Do psychotherapy now, you can.

Q: I am your psychiatrist, not a psychotherapist.

P: But you are also a psychotherapist.

Q: Yes, but I work with you as a psychiatrist and get paid for it.

P: I will pay you a hundred rubles.

B: I need a million.

P: A million?! Yes, you are an idiot!

B: No, you are crazy.

P: Why am I crazy?

Q: Of course you are crazy if you are treated by an idiot psychiatrist.

Sly smiles. Further, the conversation proceeds in a constructive manner. Agrees to wait for his analyst. He discusses his health and the effect of drugs. In this case, there is an attachment to his irritation. The patient's aggression ("the doctor is an idiot") returns similarly - "in that case - you yourself are crazy" - verbal emotional communication. The psychiatrist informs indirectly that the patient is not indifferent to him, that he also has feelings similar to the patient. It is important that the doctor pronounces the climactic phrase without affect, in a calm voice, as a statement. Agreeing with the "idiocy" of the doctor, he involuntarily has to admit his "madness", which is unacceptable for him. This defuses the situation and allows the patient to accept the rules of the therapeutic relationship.

The patient is a 22-year-old man, diagnosed with paranoid schizophrenia. Sick since the age of 18. He studied at a prestigious institute before the onset of the disease. The disease was manifested by anxiety and crazy ideas: they laughed at him, set up various situations, the special services of other countries read his thoughts. He was hospitalized several times, usually after suicide attempts. He received large doses of neuroleptics, but there was no significant dynamics. The last incomplete suicide brought the patient to a psychiatric hospital, where he underwent electroconvulsive therapy (6 shocks). Sent to the DC by his psychoanalyst for the selection of therapy, tk. had severe mental disorders: the patient complained of loss of memory and abilities, depressed mood, and delusions persisted. Attacks of anxiety and fear 1-2 times a week reached such a level that the patient had a strong desire to commit suicide (he climbed onto the roof of the house, thought to throw himself down). From the analyst there was information about his passion for computers, homosexual fantasies, "genius". At the beginning of the conversation, the patient was not interested in contact, as he believed that the doctors did not believe him. He said something about computers.

Intervention 5.

Q: Yes, I have to install an anti-virus program, otherwise they get into my computer.

Q: Everyone is interested in learning about my homosexual experiences.

P: Do you have homosexual experiences?!

Q: Why shouldn't I have homosexual experiences? All geniuses have out-of-the-box ideas.

P: Are you a genius too?!

Q: What's so amazing about that?

P: The thing is, I'm a genius too... It's like a prank. Are you joking?

Q: I think it makes sense: a brilliant patient - a brilliant psychiatrist.

P: It seems to me that you all say this on purpose ...

Q: Actually, it's more unpleasant that they could find out about my bestial fantasies ...

P: I don't believe you.

He laughs, speaks of distrust, but begins to reveal his feelings. With the same patient in a different situation, mirroring was used, which in working with him became the main "parapsychiatric" procedure.

Intervention 6.

P: Yes, you don’t believe me either, like other doctors. They read my mind, they follow me.

Q: Could you show me the cookie?

P: Not sure what to do?

Q: Show cookie.

P: Whom to show the cookie to?

Q: Could you show the cookie through the window?

Q: Some creatures got into the habit of following me.

P: Where from?

B: From the house opposite.

Shows the cookie in the direction of the window. Laughs.

P: Are you serious? I do not believe you. Maybe you want to show me that this is my nonsense?

B: Don't talk! Keep holding the cookie. Let them see what I know about them.

Continues to laugh, but holds the hand with the fig.

P: It all looks like a joke.

V: And I'm not in the mood for jokes when such surveillance.

With this patient, the mirroring technique proved to be very effective and was used throughout the course of the treatment on the ward. The doctor constantly told him that the patient was laughing at him. The psychiatrist provoked the patient to laugh - with a gaze, an ambiguous phrase, a protracted pause. This provocation could be in the corridor of the department, during a telephone conversation with him, in the doctor's office, etc. And the patient began to laugh. It should be noted that laughter here has a diagnostic value, because. it shows the ability of the patient's ego to grasp the double context of the situation, that is, the patient's thinking ceases to be so rigid, interpreting all events in a single line in accordance with delusional constructions. Or, speaking in analytical language, ego-synthonic (drives, affects, ideas, forms of behavior subjectively perceived as inherent in the Self) delusional experiences begin to acquire an ego-dystonic character (respectively, not inherent in the Self), starting to form a critical attitude to pathological ideas.

Intervention 7.

B: Well, here you are again laughing at me!

P: No. You yourself are joking.

Q: I was talking about banal things.

P: I'm tired of arguing with you. Okay, I'm laughing, but I'm not doing it viciously.

In this phrase, the patient revealed the nature of his aggressive experiences towards the psychiatrist (rage), or rather, their transformation into more positive feelings (lack of previous anger). For the first time in several years, there has been a clear positive trend, but most importantly, suicidal tendencies have disappeared. The patient began to cooperate more with those people who help him. His condition became stable, and high doses of antipsychotics were significantly reduced. It should be noted that the positive result in this patient is due to the use of a team form of work, when the analyst, group therapists and the doctor constantly collaborated with each other (3).

In psychiatric practice, resistances to classical analysis are also common, in particular, obsessive repetition (id resistance) of any questions, requests, etc. A similar example was given earlier (Intervention 4). This stereotype of behavior is quite common among the mentally ill. Rational opposition to this takes a lot of effort and is ineffective: it often causes dissatisfaction with patients who have not been answered well enough, have not been helped, have not been explained “how to”, etc. Attachment techniques can quickly change the situation.

The patient is a 35 year old male. Diagnosis - paranoid schizophrenia, alcoholism. Sick since the age of 18. The clinic of the disease gradually transformed from psychopathic to paranoid disorders. He hears the voices of demons that tempt him and torment him for his sins. Actively seeks help, but quickly refuses it under various acting-out behaviors (employment, alcoholism, fighting, etc.). Once again I came to ask for treatment. Gloomy, depressed and irritable. With the consent of the doctor to take him to the DS, he begins to repeat about alcoholism, that he is a nonentity and cannot accept help. Then the doctor says that the patient may not be treated, but this type of attachment to the idea (to be treated - not to be treated) does not work - the patient again says that he feels unwell, that he needs support. This is repeated several times. After joining the feeling (pride), the picture changes.

Intervention 8.

P: I feel bad. No strength ... I drank a lot. I feel very bad... I drank all sorts of rubbish - cheap Russian vodka, beer. I drank a lot of this muck ... I drank all the money. Now my mother supports me… Help me. I want to be treated.

Q: Yes, of course, you can get treatment from us. Come tomorrow morning, and you will be admitted to the day hospital.

P: My sickness is God's punishment for my sins. I myself must carry this Cross ... I myself must understand myself. The doctors won't help me here.

Q: Do I need to take you for treatment?

P: Yes, I feel bad. But this is my Cross. I feel bad. I am nothing.

V: No, no. I am very proud of you.

The facial expressions and posture of the patient change: he straightens up and looks at the doctor in surprise.

P: In what way?

V: I am proud of you - you are a true patriot of Russia.

P: Don't understand?

Q: You support a domestic manufacturer.

P: Don't understand?

Q: You drink a lot of Russian alcohol and thus support a domestic producer.

The patient tries to restrain his laughter, but he fails - he starts laughing. He is embarrassed. The conversation becomes constructive. Agrees to come and really comes the next day and visits DC.

If we talk about the mechanism of this intervention, then we can assume that the success was in the nature of the accession. Verbal reproaches addressed to oneself are broadcast maternal dissatisfaction with his drinking, that is, ego-dystonic experiences for the patient (as well as the desire to receive treatment), so joining them in this case was ineffective. Unconsciously, the patient is very proud of himself (ego syntonic feeling) as he is fighting Satan himself alone. Joining the emotion of "pride" for the patient resolves the resistance to the beginning of treatment. The absurdity of this pride - discharges the patient's emotional stress.

The patient is a 55 year old woman. The diagnosis is undifferentiated schizophrenia. The first mental disorders since 30 years. Receives treatment in the DS for six months. The state was determined by a pronounced disorganization of thinking, asthenia, depressive experiences, hallucinations. The patient strives for conversations that are unproductive, and is constantly dissatisfied with them: her phrases, the silence of the doctor or his "irony", the duration of the conversation, etc.

Intervention 9.

P: I get sick all the time. I've been sick for the last few years, I've been sick all the time.

Q: But now you feel better.

P .: And I communicate only with doctors. Only with doctors. What should I do?

Q: The treatment has a positive effect on you.

P: I talk to doctors all the time. Well, what is it?

Q: You are still lucky.

P: Why do you say that?

Q: For the last ten years, I have been dealing only with the sick.

Sly looks at the doctor. Stops obsessively lamenting. He talks about his well-being. In this case, we can talk about mirroring with amplification ("your environment is terrible - mine is even worse").

Obsessive repetitions, absurd requests and demands that are difficult to quickly cope with, can be quickly corrected even for "chronics" with an intellectual defect, because their mechanism of action is based on emotional communication where IQ is irrelevant. The patient is a 60 year old male. Since childhood lagged behind in mental development. WITH adolescence hallucinatory delusional experiences. Never worked due to illness, often treated in psychiatric hospitals. He was transferred from another half-hospital, because. "Tortured" doctors with a demand to increase his pension, which he was allegedly promised to increase in our DS. The patient runs into the office.

Intervention 10.

P: You promised me that they would raise my pension. My pension is not raised.

Q: What can I do - I'm only a doctor.

P: You promised! You promised! Why don't they raise my pension?!

Q: Did I promise?

P: Yes, we promised! They promised!

B: I must have been drunk.

P: Haha. You don't drink, you're a doctor.

Prior to this, the tense and anxious patient suddenly suddenly calms down, smiles and calmly leaves the office. Probably, here there was an accession to the "absurdity": the doctor could not be drunk - which means he could not promise such a thing. Another story is connected with the same patient - he was tormented by the "voices" of children's doctors. An increase in drug dosages did not reduce the intensity of perceptual delusions, but there were also complaints about side effects. Imperative hallucinations, when "voices" forced him to commit suicide (which in itself is the basis for emergency hospitalization) already caused concern to the doctor himself. An anxious and tense patient runs into the office.

Intervention 11.

P: What should I do? Children's doctors make me throw myself out the window! I'm scared!

Q: You answer them.

P: What is the answer?

B: Only after you.

P: Only after you?!

The emotional state changes dramatically - begins to laugh out loud. Immediately calms down. After this incident, while the patient was treated in the DS, there were no complaints of imperative hallucinations. Thanks to this intervention, it was possible to avoid hospitalization, the patient did not fall out of the usual social environment. The doctor joins in: the voices are not only not questioned, but a way to control them is proposed. This case proves that some symptoms of the disease, despite their "experience" and the mental status of the patient, can be amenable to psychotherapeutic correction, that is, the importance of psychological mechanisms in a psychiatric patient is clearly underestimated.

Conclusion

These approaches helped to cope with difficulties in interacting with patients, which would have taken much more time to overcome by rational methods or the effect would have been unsatisfactory. As can be seen from the above examples, psychotherapeutic techniques not only enable patients to receive the necessary psychiatric care, but also keep them within the department so that this help is more effective. Thus, the techniques of modern psychoanalysis are capable of solving purely medical problems, which makes them a valuable tool in the work of the modern psychiatrist.

Literature

1. Kernberg O. Severe personality disorders. Psychotherapy strategies / O. Kernbeg. - M.: Independent firm "Class", 2000. - 464 p.
2. Spotnitz H. Modern psychoanalysis of a schizophrenic patient: the theory of technology / H. Spotnitz. - St. Petersburg. : East-Europe. Institute of Psychoanalysis, 2004. - 296 p.
3. Fedorov Ya.O. Command factor in the organization of the work of the psychiatric department / Ya.O. Fedorov // Bulletin of Psychotherapy, 2008, No. 26 (31). – P.103-108
4. Yalom I. The gift of psychotherapy // I. Yalom. – M.: Eksmo, 2008. – 352 p.

Printed:

Fedorov Ya.O. Modern psychoanalysis in psychiatric practice / Bulletin of Psychotherapy, 2008, No. 27 (32). – P.91-101

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The use of psychoanalysis in psychotherapy

1. The main provisions of psychoanalytic therapy, as a therapy focused on psychoanalysis

1.1 Focus of psychoanalytic therapy

Psychoanalytic psychotherapy mainly focuses on the impact of past experience on the formation of such a specific behavior - through special cognitive abilities (defenses), interpersonal interaction and perception of a communication partner (transfer) - which has acquired constant repetition and thus affects health. patient.

Table 1

Focus - The impact of past experience (cognitive abilities, affects, fantasies and actions) Goal - Understanding the functioning of the patient's defense mechanisms and transference reactions, in particular, in the form in which they manifest themselves in the course of communication between the patient and the therapist

The past of the individual exists in his present, thanks to memory and biology. The expected prediction of the present and future is formed on the basis of experience, past and biology. In the same way, the patient's metaphorical language may reflect some special organization (a set of feelings, thoughts and behaviors) formed in the past and affecting his current abilities, perceptions and behavior. By exploring the present meaning of events in the context of the past, the psychotherapist-psychoanalyst seeks to change these "organizing systems" of his behavior, helping to ensure that information and experience are organized differently in the future. Psychoanalytic psychotherapy is based on the principles of the functioning of the psyche and psychotherapeutic techniques originally developed by Sigmund Freud. Freud began his work with hypnosis, but later came to free association as a method of understanding the unknown unconscious conflicts that arose in the course of human development, starting from childhood, and continued into adult life. Such conflicts are those behaviors that were laid down as clusters of feelings, thoughts and actions. They arose as a result of the interaction of various events in the individual developmental history of a person with a biological predisposition.

Usually such unconscious conflicts arise either between libidinal or aggressive desires (drives) and fear of loss, fear of retribution and limitations determined by reality, or in a clash of opposite desires.

"Neurotic" conflict can lead to anxiety, depression and somatic symptoms, stunted professional and social growth, sexual difficulties, and interpersonal relationships that make adjustment difficult. Such unconscious neurotic conflicts manifest themselves quite obviously as the patient's manner of behaving, feeling, thinking, fantasizing and acting. Perceived in childhood, they may correspond to the patient's childish view of the world around them, be adaptive and even necessary for survival in a certain period. Even if these conflicts are not initially recognized by the patient, in the course of psychotherapeutic work they come to the surface, and many of their consequences become more obvious.

Psychodynamic psychotherapy can be short-term and long-term. Treatment can last for months or even years. Freud noted that working with the unconscious requires continuity, regularity and stability. From this position follow his recommendations regarding the spatial and temporal organization of the therapeutic environment. Long-term treatment, in fact a date, does not have a fixed end, and the end date is difficult to set at the beginning of the treatment process. The duration of treatment depends on the number of conflict zones that must be worked out during such treatment. Psychotherapy sessions are usually held two to three times a week, although for short-term treatment, one session per week is the usual norm. More frequent meetings with the doctor allow him to penetrate deeper into the inner life of his patient and lead to a more complete development of the transference. Frequent meetings also support the patient throughout the treatment period.

1.2 Basic techniques of psychoanalytic therapy

In our work, we will consider some psychoanalytic techniques, namely the working alliance, the method of free association, transfer, interpretation.

Working Alliance.Behavioral change occurs in psychodynamic psychotherapy through two processes: the understanding of cognitive and affective processes emanating from childhood (defense mechanisms), as well as the understanding of the conflict relations formed in the patient with the most important objects in childhood, and their resurrection in the relationship with the therapist (transfer). Diagnosis of understanding such feelings and perceptions is the focus of treatment. The treatment environment should be organized in such a way as to make it as easy as possible to bring these phenomena to the surface, and in such a way as to make it possible to analyze them without mixing them with the reality of the relationship between the patient and the doctor and not dismissing them as something trivial.

A necessary initial condition for success in psychoanalytically oriented psychotherapy is the patient's own need to take part in such work and his confidence in his relationship with his therapist. R. Greenson gives this component the name "working alliance". The working alliance is manifested in the patient's willingness to follow the rules of psychoanalytic procedure and cooperate with the analyst. Such an alliance is built on the realities of treatment - working together to achieve a common goal, as well as the constancy and reliability of the therapist. It is only in contrast to the established therapeutic alliance that the patient can view his transference feelings and become aware of the relationship distortions that these feelings bring. It is important to note that what the patient brings to be considered in psychotherapy is the main focus of treatment. The depth of interpretation and research should always be at the level of the patient's momentary needs, not to lag behind and not to get ahead of his thoughts and feelings.

Free associations. Free association method- a psychoanalytic procedure for studying the unconscious, during which the client freely speaks about everything that comes to mind, no matter how absurd or obscene it may seem. Free association of the patient should be encouraged. This is achieved in a very simple way. The patient is told that he is free to talk about anything. The main task of the therapist in this case is to listen to the deep currents of the patient's associations. This implies understanding the connection of one story with another, identifying the patient's attitude to the person he is talking about, paying attention to the impressions that the patient has about his doctor. Often, hearing some ambiguity in the patient's associations, the therapist can open the way to an unconscious conflict and a significant person from the patient's past with whom this conflict is associated.

« For example, a patient comes to see a psychotherapist immediately after an argument with his girlfriend and says, "I want her back." If you catch the double meaning here in the sentence - to be with her again or to get her back in order to take revenge on her - then you are unlikely to be surprised to hear that, although the patient said at the beginning that he wanted to be with her again. his girlfriend, by the end of the session he is already describing his fantastic retribution. (His fantasy was borrowed from an old movie. He fantasized about the pleasure with which he would smear a grapefruit on the girl's face.) Conflicting feelings - longing for her and a feeling of hatred - are already indicated at the beginning of the session. This usual pattern of reaction to rejection developed for him in his childhood relationship with his mother, who probably experienced the same conflicting feelings for him and once drove him out of the house at knifepoint. Of course, he was not yet ready to hear about such a connection, but it was already becoming quite obvious. This "pattern" could now be observed and guided the patient along the path of gradual, slow awareness. .

Transfer (Transfer).In psychoanalytic psychotherapy, one of the most important tools in the hands of the therapist is the development and understanding of transference. Transfer (transference) is an unconscious reproduction by the patient in the relationship "here and now" of the early experience of relations with important people from your surroundings. Thus, feelings and impulses of past conflicts are projected onto a real person in the present (for example, a psychoanalyst). Transference is a wave from the past that overwhelms the present and leaves traces that cannot be confused with anything. Transference is the driving force behind the process by which the patient's difficulties "come to life and materialize" in the therapist's office, allowing for a deep examination of what they are and how they are realized in his real and significant environment. In fact, this is what distinguishes psychodynamic psychotherapy from all other forms of psychotherapy more than anything else, namely understanding the transference and analyzing it, rather than simply trying to overcome it.

One way to understand the concept of transference is to imagine that the human brain is partly made up of sets of memories for each of the important people from past this person. Such organized sets of memories are called "object representations" and when a person meets another, unfamiliar person, he or she begins to form a new object representation. Needless to say, such a process begins and is carried out to a certain extent only when a new person is of interest to the observer, but when such a process begins, the observer, trying to understand his new acquaintance, begins to rummage through his memory in search of those standards that allowed to evaluate and compare the new individual. Soon, both old and new object representations are psychologically linked, responding to the observer's need for familiarity or some other psychological need. The stranger is studied through ideas, thoughts, and feelings that were originally intended for an old friend, relative, loved one, or enemy.

Much of human psychic activity is aimed at keeping the unconscious beyond the conscious with the help of a special way of thinking. Due to the fact that the transference usually brings to life long forgotten, conflicting aspects of the relationship, very often the patient seeks to reject the feelings, thoughts and memories contained in them and, at the same time, rejects the psychodynamic psychotherapist and generally tries to interrupt the therapy. Such resistant transfer ideas must be understood in order to use transfer effectively to achieve a successful treatment outcome.

Interpretations.The objects of interpretation can be: transference, external reality, the past experience of the patient and his defense mechanisms.

Kernberg distinguishes clarification, confrontation and interpretation proper in the process of interpretation. The first step in interpretation is clarification. It is an invitation to the patient to explore material that appears nebulous, mysterious, or contradictory. Clarification has two goals - to clarify certain data and to assess to what extent the patient is able to realize them. At this stage, the analyst turns to the conscious and preconscious levels of the psyche. Technically, the clarification procedure looks something like this: the psychoanalyst selects one of the aspects of the patient's verbal or non-verbal behavior in the session, focuses his attention on it and offers it as material for association. As a result, new, hitherto unexplained phenomena come into the field of analysis.

Kernberg gives a number of examples of the clarification technique:

a) “I have noticed that whenever I move my chair, you glance at your watch anxiously. Do you have any thoughts on this?" (transfer clarification);

b) “You keep repeating that any woman in your place would do the same as you, and that you do not see anything special in your feeling of disgust for men. Could you explain your point of view?” (clarification of the alleged defense mechanism).

The second step in the interpretation process is confrontation. It brings the patient to the realization of contradictory and inconsistent aspects of the associative material, draws his attention to facts that were not previously realized by him or were considered self-evident, but at the same time contradict his other ideas, views or actions. In the process of confrontation, the analyst can relate the material of the current session to external events in the patient's life, thereby revealing the possible connection of the therapeutic relationship "here and now" with his other interpersonal relationships. The object of confrontation, as well as clarification, can be transference, external reality, the past experience of the patient and his defense. Here are examples of confrontation:

a) “You rejected without hesitation all the considerations expressed by me during today's session, and at the same time repeated several times that you did not receive anything from me today. What do you think about it?" (confrontation relating to transference);

b) “There is a feeling that the desire to find another woman appears in you every time you unexpectedly discover traits that you like in the character of your partner” (confrontation related to defenses).

Like the clarification stage, the confrontation addresses the conscious and preconscious levels of the patient's psyche, setting the stage for interpretation. Interpretation completes a single interpretative cycle by linking the patient's conscious and preconscious material to putative unconscious determinants. Its goal is to achieve a therapeutic effect by bringing to the patient's consciousness his unconscious motives and defenses and thereby removing the inconsistency of the material reported by him. Interpretation is a psychoanalytic device, the most profound in its impact on the patient.

The analyst can interpret transference, external reality, the patient's past experiences and defenses, and link all of these observations to the patient's supposed unconscious past experiences (such interpretations are called genetic interpretations). Let's look at some examples:

a) “It seems to me that you are trying to provoke me into an argument with you in order to drive away sexual fantasies about me. What do you think about it?" (transfer interpretation);

b) “Perhaps your attempts to deny the presence of hidden attacks on you in the speech of your political opponent indicate how much you are afraid of the intensity of your own hatred for him” (interpretation of the defenses);

The main principles of psychoanalytic interpretation include the following:

First of all, you should interpret the material that prevails in this session. The analyst, however, should only interpret when, in his opinion, the patient is unable to do so on his own.

First, the material that is closer to consciousness is interpreted, and then - deeper, less conscious. In accordance with this principle, the psychoanalyst first interprets the defenses and only then the content hidden behind them.

In interpreting the fact that the patient is not aware of anything, the analyst must include in his interpretation an indication of the possible motives for this defensive "unawareness". By offering the patient an explanation of why he resorts to such a defense, the analyst thereby helps him to accept this content that he rejected.

The interpretation must include a description of the conflictual nature of the patient's mental dynamics.

The psychoanalyst should only interpret under the following conditions:

a) he is able to more or less clearly formulate an assumption about what is behind the patient's statement;

b) he is sufficiently sure that if the patient agrees with this assumption, the level of self-consciousness of the latter will increase; if the interpretation turns out to be wrong, it will still serve to clarify the situation;

c) it seems unlikely that the patient will be able to come to this conclusion on his own, without the aid of the analyst's interpretations.

Until all three of these conditions are met, the psychoanalyst either remains silent or confines himself to using the techniques of clarification and confrontation. When they occur, they should be interpreted as soon as possible.

1.3 Indications and contraindications

Psychoanalytic psychotherapy uses specific technical means and a specific understanding of mental functioning for the selection and implementation of appropriate interventions by the therapist. As with other types of treatment, there are indications and contraindications.

Psychodynamic psychotherapy achieves better results with mental disorders of the "neurotic" level. The roots of such conflicts, as a rule, lie in the "oedipal complex", and the patient usually experiences them as "internal". These are obsessive-compulsive disorders, anxiety disorders, conversion disorders, psychogenic somatic illnesses, dysthymia, mild to moderate affective disorders, adjustment disorders, and mild to moderate personality disorders. Those patients who are able to think in psychological terms, to observe feelings without reacting to them in action, who are able to achieve relief of symptoms through understanding, can receive great help from psychodynamic psychotherapy. The patient who is in an environment that can support him in the family, with friends, at work - usually achieves greater success, as he uses therapy more effectively. Such a patient does not need a therapist as an initial source of support under the stresses of life or treatment. Patients with more serious illnesses such as severe depression, schizophrenia or borderline personality disorder can also be treated with psychodynamic psychotherapy. For such patients, treatment is usually aimed at modifying the factors that caused the disease, better adjustment, getting rid of symptoms and returning them to normal life. Patients with severe "preoedipal" pathology cannot be considered suitable candidates for treatment with psychodynamic psychotherapy. This is manifested in their inability to form mutually supportive dyadic relationships, their preference for exploitative relationships in a chaotic lifestyle, real (and even dangerous) emotional reactions. The main requirements of psychodynamic psychotherapy - that the patient must have a strong observing ego and the ability to establish a mutually supportive therapeutic relationship - such patients cannot afford

Freud believed that since psychotic patients are essentially narcissistic, they cannot be treated by psychoanalysis, since they cannot develop a transference neurosis. The division remains in place, but today many patients who cannot be neatly assigned to one category or the other because they have features of both neurosis and psychosis are treated in this way. Moreover, at the present time some analysts find it possible to carry out classical analysis with psychotics and achieve good therapeutic results. . Most analysts, however, are of the opinion that narcissistically fixed patients require changes in standard psychoanalytic procedure.

2. Kohut's contribution to modern development psychoanalytic psychotherapy

.1 Kohut's main ideas in the theoretical construction of the psychology of the self

Kohut developed an aspect of Freud's concept of narcissism that allowed him to completely move away from drive theory and strongly put forward a theory of the "I". Before Kohut, narcissism was considered a pathological condition in which a person - like the mythical Narcissus admiring his reflection in a forest lake - considers his body and his personality as the center of the universe and the only criterion of value. We all know people who talk only about themselves or their experiences, without attaching any importance to the thoughts and feelings of others. Kohut realized that such a state is an aberration (distortion) in the essence of the normal process and that going through a period of narcissism is a necessary and healthy stage of growing up. Every infant and young child should feel like the center of the universe, at least for a while. The resulting emptiness will cause a narcissistic desire for attention, which later becomes a personality defect only when this feeling is denied. Kohut saw that normal narcissism forms the core of the self.

According to Kohut, there are three strong needs that must be satisfied if the self is to develop fully: the need to "reflect" (to be reflected in another person), the need to idealize, and the need to be like others.

Kohut called these reflective and idealized people I-objects (objects of the Self), because it seems to the child that they are an extension of himself. Over time, the child will internalize relations with self-objects in such a way that he will be able to carry out the operations of reflection and idealization within himself. When these two processes of internalization are successful, they form the basis of the bipolar self. The internal process of reflection leads to realistic aspirations in the world, reinforced by the mother's internalized stimulating praise. Equally, when the idealized father is internalized, the child may aim at realistic ideals. These two poles form the core of a healthy self and generate felt aspirations and ideals that provide a sense of purpose and meaning. Kohut called the third need of the developing self "similarity" or "twinship", or the need for an alter ego.

According to H. Kohut, if the above needs are adequately satisfied, the child develops a healthy Self, which entails high self-esteem, well-functioning management of the system of ideals and values, and confidence in the development of their own abilities. If these needs are not satisfied enough, then the self will be found to be flawed, which will interfere with healthy development and create life problems. H. Kohut called these problems self-disorders.

Kohut defines Self, as a psychological structure through which the experience of oneself acquires coherence and continuity in time, thanks to which the experience of the self takes on its characteristic and stable organization, and which relates to the structure of the individual's experience of himself. This self is built of "structures" that result from transformative internalization. In accordance with Kohut's formulation, the self is bipolar in nature, consists of two main components - core ambitions and guiding ideals - arising from the transformation and internalization in the process of development, respectively, of the mirroring and idealizing functions of the object of the self. Ambition pushes us forward, and ideals point the way. In a child at an early stage, both poles are still combined due to exhibitionistic omnipotence and voyeuristic perfection, that is, a child at the stage of grandiosity. Parents should allow the child to go through this stage normally, without fixations and injuries. According to Kohut, “if traces of ambition and idealized goals begin to be acquired in parallel in early infancy, then the main part of nuclear grandiosity is combined into nuclear ambitions in early childhood (perhaps primarily in the second, third and fourth years of life), and the main part of nuclear idealized goals structures are acquired in late childhood (perhaps primarily in the fourth, fifth and sixth years of life).

It is believed that between these two poles of the Self, a constant current of psychological activity is established, metaphorically described as an "arc of tension." This arc of tension is considered a source of motivation for the basic life aspirations of the individual. Compared with the theory of drives and the structural theory of psychoanalysis, the innovation of the psychology of the Self, - L. Koehler believes, - lies in the fact that the Self and the so-called need for an object of the Self are considered within this psychological system as the main factor of motivation. The possibilities of analysis and psychological processing of many transference phenomena increase significantly if they are considered as an expression of the need for an object of the Self, and not as a consequence of impulsive desires. The Self-Object is the object without which it is impossible to maintain self-regulation. The object of the Self is perceived as a part of oneself, as a part of one's own body, for example, a hand.

If the classical theory of psychoanalysis says that in the course of psychological evolution narcissism is transformed into love for an object, the feeling of symbiosis is replaced by autonomous ideas about oneself and object ideas, then, according to the psychology of the Self, in parallel with the formation of these ideas, the evolution of the Self and objects of the Self continues, during which archaic forms are replaced by mature forms. The objects of the Self retain their functional significance throughout life and are necessary for the maintenance of normal mental content. According to the psychology of the Self, the goal of psychotherapy is to help the patient get rid of the feeling of fusion or symbiosis and not only to throw off the shackles of emotional dependence on the object and achieve stability in the relationship with the object, but also to form a more mature object relationship to himself. As a result, the patient's Self becomes more stable, his capacity for empathy increases, due to which he is able to calmly accept the fact that the initiative comes from the object itself.

2.2 Analysis of the analytic technique of transference work as a therapeutic work with narcissistic disorders

According to Kohut, patients with narcissistic personality disorders are subject to psychoanalytic treatment. Features of the self-experience of people with a narcissistic diagnosis include "feelings of vague falseness, shame, envy, emptiness or incompleteness, ugliness and inferiority, or their compensatory opposites - self-assertion, self-respect, contempt, defensive self-sufficiency, vanity and superiority" .

Instead of being overwhelmed by raging primitive introjects, these people complain of emptiness - more of the absence of internal objects than of being engulfed by them. “These people,” writes N. McWilliams, “turned to therapy in order to find the meaning of life. They were deprived of a sense of inner direction and reliable guiding values.

Narcissistically structured people are at some level aware of their psychological characteristics. They are afraid of separation, a sharp loss of self-respect, self-responsibility. they feel that their identity is too fragile not to crumble and withstand some tension.

H. Kohut, working with people who are waging a desperate struggle with inner emptiness, and not being satisfied with the Freudian psychoanalytic diagnosis of repressed sexual and aggressive energy, concluded that such patients suffer from insufficient development of the "I". He writes: "...despite the initial vagueness of the present symptomatology, most of the important symptomatic features can, as a rule, be clearly recognized in the process of analysis, especially when one of the forms of narcissistic transference is established" .

H. Kohut focused his research and therapeutic developments on understanding the nature of narcissistic transferences and the technique of working with them. H. Kohut thinks in terms of several subtypes of self-object transference that occur in narcissistic patients, namely mirror, twin, and alter ego patterns.

So, H. Kohut “divided the transferences of the I-object into three groups:

the damaged pole of ambition tries to evoke affirmative-approving reactions of the self-object (mirror transfer);

the damaged plus of ideals seeks the I-object that approves of its idealization (idealizing transference);

the damaged intermediate area of ​​talents and skills is looking for a self-object that will make itself available to a confirming experience of significant similarity (twin transference or alter ego transference).

In the "mirror" transfer, three levels are distinguished in accordance with the three levels of regression. The most archaic is the level of "fusion" or "acquisition", where the grandiose I spreads to the analyst, it seems to envelop him. Less archaic is the "Alter Ego" or "double" level. The least archaic form is the "mirror" transfer in the narrow sense. The fragility of the grandiose self requires empathy and the normal "mirror" functions of the mother as a self-object. Her love and devotion allow the grandiose self to consolidate at first, and later develop into more mature forms of self-respect and self-confidence through less and less archaic types of “mirrors”. At the same time, optimal relations with the “reflecting” Self-object contribute to the development of the normal idealization of the Self-object, which replaces the original perfection of the grandiose Self, which is now partially preserved in relation to such an idealized Self-object. Such idealization eventually ends, according to Kohut's terminology, with the "transformative internalization" of the idealized Self-object into an intrapsychic structure that gives rise to the Ego-ideal and the ability of the Super-Ego to idealize, which preserves new type internalized regulation of self-esteem.

Kohut considers narcissistic pathology as a consequence of traumatic weakness of maternal empathy and disturbances in the development of idealization processes. “The balance of primary narcissism is disturbed by the inevitable lack of maternal care, but the child replenishes the former sense of perfection by a) forming a grandiose and exhibitionistic image of himself - a grandiose self, and b) endowing the former perfection with an admirable, omnipotent (transitional) object of the self: the idealized parental imago” . These configurations of experience are available for study and research in analysis, and as a result of proper elaboration, they can be transformed and softened.

In the course of analysis, the psychoanalyst should be allowed to develop a narcissistic idealization and not be destroyed by interpretation. This allows the mirror transference to gradually develop as well. The psychoanalyst becomes an I-object, providing a process of transformative internalization. He needs to be empathic, focusing on the patient's narcissistic needs and frustrations rather than the conflicts that cause those frustrations. Weakness of empathy on the part of the analyst leads to partial fragmentation of the grandiose self, narcissistic anger, diffuse anxiety, hypochondriasis, and even more severe states of depersonalization and pathological regression with cold paranoid grandiosity. In each such case, the analyst explores with the patient when and how the former did not show empathy and how this relates to traumatic situations in the patient's past.

Kohut emphatically emphasizes that this does not require setting the parameters of the technique. It is only a modification of the standard psychoanalytic technique, differing from the analysis of non-narcissistic patients only in that it emphasizes empathy - as opposed to "objective neutrality" - and focuses on changes in the self, rather than drives and (as yet non-existent) interstructural conflicts. In the technique of narcissistic gratification he described, one can clearly see "... liberation from the fetters of the rules of abstinence." In essence, Kohut advocated the principle of security. Its proponents point out that the frequent negative therapeutic outcome with the standard technique reflects a lack of psychotherapeutic support. Given the limited resources of the Ego and the lack of support, it is extremely difficult for the patient to work out transfer options. “Because of the devaluing and exploitative maternal attitudes in the past, the patient chronically feels his “badness and worthlessness”. Narcissistic anger is a defense to regulate self-esteem. Confrontation with hostility and envy only reinforces the initial feeling of "badness". With a weak realistic basis of the therapeutic relationship and a pronounced structural deficit, confrontation results in an "unbearable balance of goodness", "badness" and "power" (Epstein L., 1979)" . The processing of narcissistic anger in the transference does not lead to intrapsychic integration, but only confirms the "badness at all". Severe narcissistic patients are only able to accept and trust positive feedback that is perceived as a response to their efforts to "be good."

It is empathic understanding that allows anger to be softened and calmed, as it should be done in early childhood. The responsiveness of the analyst, by making up for the lack of empathy on the part of the mother figure, promotes transmuting microinternalizations. The correction of structural defects occurs due to the gradual acceptance by the patient of the functions of the therapist as the Self-object for the regulation of anger and understanding of narcissistic needs.

In therapy, Kohut distinguished 6 stages:

Stage of strong resistance;

The phase of oedipal experiences in the traditional sense, dominated by experiences of severe castration anxiety (oedipal complex);

Resumption of strong resistance. Called like this:

increased anxiety;

re-experiencing previous development;

fear of the next step.

Stage of disintegrative anxiety. Here we can reach a new stage from which a new development is possible.

Stage of moderate anxiety. The analyst must be prepared to dive into psychotic anxieties. Disintegration anxiety decreases, the joyful expectation of a new development persists, this new development begins;

Normal passage through the oedipal stage.

The process of analysis can move in a V-shaped arc, or in a spiral, necessarily with access to a new round of development.

Kohut describes therapy as a loop, that is, we go from the pathological experience of the Oedipal period, which formed the Oedipus complex, we go down and down, until the period of formation of the archaic self (the fourth stage), starting from the platform of the archaic self, we go up again. The transference neurosis is constantly growing. Then the process of normal separation begins (the analyst begins to slowly “let go” of the patient). The processes of revealing internal potentials begin, the patient begins to acquire and feel all the new abilities of autonomous functioning. It ends with the patient entering the oedipal period, which is experienced as a joyful, non-traumatic, hopeful event and new life.

Criticism of the theory and therapeutic guidelines of Kohut is primarily carried out by O. Kernberg. In his opinion, Kohut does not distinguish between normal and pathological types of transference idealization. He also does not share the concepts of "separateness" and "differentness"; the former, according to Kernberg, is absent in schizophrenic patients, and the latter in narcissistic patients. The main thing is that H. Kohut does not distinguish between the normal grandiose I in childhood and the pathological grandiose I. Kernberg considers it wrong that Kohut rejects the interpretation of the negative transference and even artificially strengthens the idealization in the transference. In his opinion, Kohut's supportive, reeducational approach to narcissistic patients helps them rationalize their aggressive responses as a natural result of the unfortunate actions of others in their past. At the same time, there is no radical reorganization of the unconscious past through the processing of transfer neurosis.

The essence of criticism follows from various opposing positions. Kohut considered pathological narcissism in terms of development (the patient's maturation proceeded normally and met with some difficulties in resolving the normal needs of idealization and de-idealization). Kernberg, on the contrary, understood it in terms of structure (something went wrong very early in allowing the individual to surround himself with primitive defenses that differ from the norm in quality rather than in degree). The concept of Kohut's narcissistic personality can be illustrated by the image of a plant whose growth was stunted as a result of insufficient watering and lighting at critical times. Narcissus Kernberg can be thought of as a plant that has mutated into a hybrid. The takeaway from these various theories is that some approaches to narcissism emphasize the need to give the plant enough water and sun to finally grow, while others suggest that deviant parts must be pruned out so that the plant can become what it should be. . Thus, self-psychologists recommend a benevolent acceptance of idealization or devaluation and unwavering empathy with the patient's experiences. Kernberg advocates a tactful but persistent confrontation with grandiosity, appropriated or projected, and a systematic interpretation of defenses against envy and greed. Self-oriented therapists try to stay inside the patient's subjective experience. Analysts influenced by ego psychology and object relations theory, on the other hand, vacillate between an inward and an outward position.

As already noted, H. Kohut believed that the basis of a mental disorder is not a conflict, but a lack of emotional warmth in early childhood, which can and should be compensated for in the relationship between the patient and the analyst. At the same time, the psychoanalyst is not forbidden to admire the patient and show him respect.

Kohut believed that it was the therapist's job to provide corrective emotional experience and that empathy was the main component of such experience.

On the basis of empathic understanding, the patient's inner state can be explained in terms of his narcissistic needs and developmental frustrations, especially in relation to archaic states of the self. “Through his experiences in the course of the analysis, the patient comes to realize the separation between himself and the analyst; awareness that arises with the help of appropriate "non-traumatic frustrations" carried out by the psychoanalyst. This leads to what H. Kohut calls "transmuting internalization" in the patient (that is, a structural change), as a result of which the ability of the latter to take on and perform important functions of a self-object is enhanced. Progress in treatment seems to be based on the systematic working through of the process of narcissistic connection, which eventually moves the figure of the analyst from the status of a self-object or partial object to the status of a separate person with his own real traits and shortcomings.

Thus, an essential role in H. Kohut's technique of psychology of the Self is played by the analyst's empathy. Moreover, Kohut argued that the essence of empathy can only be grasped in the context of the psychology of the Self. It is seen as an important way to achieve an understanding of the internal state of the patient. Based on the theory of psychology of the Self, the analyst is able to achieve such a high empathy for the experience of the analysand that he feels himself a part of him, and vice versa.

“In the process of analysis, only the psychic, inner reality of the patient matters, which is known only with the help of empathy, that is, substitutional introspection. An objective and neutral position allows only assessing the patient's experiences from the point of view of an outside observer, and not opening them from the inside.

H. Kohut writes: “The best definition of empathy is to look at it as the ability to understand and feel oneself in the context of the inner life of another person. It represents our lifetime opportunity to experience what another person experiences, however, as a rule ... in a weakened degree.

G. Etchegoen and other critics believe that “in order to preserve the empathic connection, Kohut refused those interpretations in which the analysand could “feel” hostility and threat. Apparently, the desire to maintain an empathic climate under any circumstances had a serious impact on Kohut's views, forcing him to almost completely abandon the theory of conflict and momentum. When empathy is understood mainly as a way to protect the patient from the painful truth about himself, the scope of this concept becomes extremely narrow. Kohut does not reject interpretations in which the analysand feels hostility. In response to these remarks, we would like to respond with the words of Kohut: “... any interpretation or reconstruction consists of two stages: first, the analysand must realize that he has been understood, and only then, in the second stage, the analyst will demonstrate to the analysand certain dynamic and genetic factors explaining the psychological content that he first grasped empathically. According to Kohut, the first thing every therapist must do is open himself to an empathic experience that allows him to see the world from the client's point of view. The next task is to let know that the therapist really understands him. Michael Kahn wrote: "The first thing that sets Kohut apart from other therapists is the focus on allowing clients to know that you are doing everything in your power to understand his, the client's, views." (3, 64)

Already in his first works, Kohut argued that “psychological facts are collected only through introspection or empathy. This, according to G. Etchegoen, was a revolutionary innovation: empathy was recognized not only as a prerequisite for analytical work (which had been known since the time of Ferenczi), but the very essence of the method. Kohut has given empathy a methodological carte blanche.

In our opinion, Kohut is indebted to two points of view on empathy. First of all, Kohut identified empathy as a way of observing and collecting data. This idea is also clearly expressed in his definition of psychoanalysis as a discipline that bases its observations on introspection and empathy (transformative introspection). Kohut believed that empathy allows the therapist to experience the experience of the other without losing the ability to objectively assess the other's mental states. In addition, Kohut considered empathy to be a universal developmental need. The infant's experience of the caregiver's empathic mirroring is a necessary component in the development of the Self, and, conversely, traumatic failures in providing empathic mirroring play a critical role in the development of defects and pathology of the Self.

Conclusion

Over the past 100 years, psychoanalysis has become much more complex, new analytical concepts and entire schools have arisen. Psychoanalytic psychotherapy, as a psychotherapy based on psychoanalysis, has now expanded the categories of patients it can help.

Using the example of Heinz Kohut's theory of the development of the Self, we have shown that psychoanalytic theory develops, expanding the possibilities of psychoanalytic psychotherapy.

Kohut began to consider narcissism not only as something pathological, but also as an independent line in normal development. Kohut focused on three strong needs that must be satisfied if the Self is to develop fully: the need to "reflect" (to be reflected in another person), the need to idealize, and the need to be like others. The structures that make up the Self build up gradually through transmuted internalizations. When parents are more supportive because they reflect idealized images and alter egos, their inevitable failures allow children to provide these functions for themselves.

Patients experience difficulty because their parents have failed to provide their children with some (or all) of these features. Therefore, the therapeutic task is to enable the patient to build those structures that did not develop in him in childhood.

According to H. Kohut, the structures of the Self are built in therapy in the same way as they were built in early age. If the analyst is mostly empathic, then conditions are created for building structures. Failure is inevitable. The analyst may be in a bad mood or distracted, or simply lose the thread of the patient's story, and so on. If the current errors are not too frequent, not traumatic, and the analyst acknowledges them with empathy and without security, then again it is possible to provide empathy without outside help. In successful therapy, structures are built gradually until the initial deficit is exhausted or until adequate compensatory systems are established.

Kohut discovered narcissistic types of transference, described them and developed an analytical technique for working with them. This was the start new era psychoanalysis, since the spectrum of psychopathology in which psychoanalysis has now become effective has expanded dramatically. He found that defects in the structure of the Self in narcissistic patients become apparent in three situations of transference: in mirroring transference, the patient tries to correct these defects by perceiving the therapist as someone completely fascinated and delighted by the patient. The patient has an insatiable need to tell about every detail of his life. In idealizing transference, the patient transforms the analyst into a person worthy of reverence and admiration, and then begins to feel his own importance and worth as a result of their relationship. In twin transference, the patient fantasizes that he and the analyst are in some way equal partners on a journey through life together. In this case, the patient no longer feels alone or empty. In all three transference models, the psychotherapeutic intervention is broadly similar: a deep empathic understanding on the part of the analyst. The transference and the relationships it generates are accepted and understood by the analyst, and as a result the patient can gradually internalize the analyst's personality. Thus the psychic organization which the patient could not carry out with his parents is now successfully structured and his health restored.

H. Kohut considered therapy as a process consisting, first of all, of such components as understanding and explanation. The first task of an analyst is to understand his customers as deeply and completely as possible. The tool of such understanding is empathy, and the necessary condition is the utmost openness. Empathy was recognized not only as a prerequisite for analytic work (which had been known since the time of Ferenczi), but also as the very essence of the method.

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2. Who benefits from psychoanalytic therapy?

3. What types of psychological problems can be solved in

psychoanalytic therapy?

4. What should a patient do when applying for

psychoanalytic help?

5. How does a psychotherapist - psychoanalyst work?

6. What is the unconscious?

7. Why are dreams especially important in psychoanalysis?

8. Why is the couch used in psychoanalysis?

9. What is resistance?

10. What is transfer?

11. Should psychoanalytic therapy focus on

only on the events of early childhood?

12. Does psychoanalysis focus only on sex?

13. Is it possible for a patient to fall in love with a psychoanalyst?

14. Is there psychoanalytic therapy carried out in

groups?

15. How long does it last

psychoanalysis?

17. How has psychoanalysis changed since Freud?

18. Are there different schools of psychoanalysis?

forms of therapy?

20. Is psychoanalysis just a fad or outdated

therapy technique?

reality?

22. Can a person change himself, only at the expense of his

willpower?

23. Is it possible to use introspection?

24. How do you train to be a psychoanalyst?

25. How much does psychoanalytic treatment usually cost?

26. How often do psychoanalytic sessions take place?

27. How to choose the right psychoanalyst?

28. Does a psychoanalyst have to be male (or

woman)?

* * *
1. What is psychoanalytic therapy?
Psychoanalytic therapy is a psychotherapeutic method

treatment intended (in the broadest sense) to heal

from intellectual and emotional distress. From worldly

experience we all know how often a simple conversation we

helps psychologically; besides, it's amazingly simple

a technique that does not involve any special actions whatsoever

on the part of the patient, nor on the part of the therapist. Psychoanalysis is

as a method of self-comprehension, and a general methodology for studying

human behavior, one of the branches of scientific psychology.

Psychoanalytic therapy is based on the idea that much of

our behavior, thoughts and attitudes are controlled by the unconscious

psyche, and not through the usual conscious volitional control.

By inviting the patient to speak, the psychoanalyst helps him identify and

manifest his unconscious needs, urges, desires and

memories so that the patient can gain conscious control

over your life.

This form of treatment for emotional problems was first

developed by Sigmund Freud in the first half of this century.

Subsequently, many psychoanalysts, relying on the work

Freud, expanded the range of problems that can be solved with

with the help of psychoanalysis. Along with new practical techniques

treatment also emerged and new models in the understanding of human

behavior.
2. Who benefits from psychoanalytic therapy?
Psychoanalytic therapy is beneficial for anyone

who wants to have more happy life and have more

personal and emotional flexibility. Adults, children, lovers

couples and entire families can participate in therapy. At the same time they

can attend both individual sessions of psychoanalysis, and

take part in group work.

3. What types of psychological problems can be solved in

psychoanalytic therapy?

With the help of psychoanalysis a very wide range of

range of psychological problems (especially emotional). More

detail:

Emotional pain, depression, boredom, anxiety.

Inability to learn, love, work, or express

emotions.

- irrational fears, anxiety without specific

known reason.

Feelings of insignificance, emptiness, uncertainty

future.

Lack of goals, meaning of life, ideals.

Feeling like you're overwhelmed with responsibility

unable to relax and play.

Failure to establish for oneself practical, achievable

life goals and take responsibility for achieving them.

Unsatisfactory relationship with spouse

children or parents.

Inability to establish and maintain friendships or

love relationship

The feeling of a "man-sand" who is absolutely not

controls his life and believes that everyone is not the master of his own

fate.

- an overly regimented life dominated by

rituals and obsessions.

Binge eating or inability to eat enough

for good health.

Health problems that have a psychological

origin.

4. What should a patient do when applying for psychoanalytic

help?
The psychoanalytic patient is an equal partner

It's tricky to go about discussing certain topics.

Wanting to do something else, rather than participate in the conversation.

Wanting advice, not understanding.

Talk only about thoughts and ignore feelings.

Non-reverse, share only your feelings without revealing

their understanding.

These and many other forms of possible resistance

impede self-knowledge of the patient, his personal growth, and in general

becoming the person he wants to be. Together patient and

analysts study the meaning and purpose of a particular resistance and

trying to find the key to unlock it in such a way that

the patient continued his personal growth. Modern therapists

believe that the patient necessarily feels the need for

resistance, and use a gentle approach to help him

overcoming the problems of resistance.
10. What is transfer?
Already the first psychoanalysts in their work discovered that

patients may have a highly distorted perception of the analyst.

For example, an analyst with a quiet, polite manner might be

perceived as an overwhelming tyrant. Alternatively, the patient may be

convinced that the analyst is in love with him, even if no

there were no real expressions of love.

These kinds of feelings usually come from typical

relations to significant parental figures, which in the past

The patient was a parent, teacher, brother or sister. Sometimes

feelings towards the analyst represent actual feelings,

directed at a real person from the patient's past, but

transferred at the present time to the nearest and most suitable

parent shape - i.e. for analytics.

Not all patients experience classic forms

transfer, but for almost all patients during the analysis

it is useful to study and understand the feelings that arise in them

relation to the analyst. This is very helpful in understanding the current

relationships, the severity of the need for personal growth,

expectations from others and attitudes towards the patient.
11. Should psychoanalytic therapy focus only on

on the events of early childhood?

The events of the first five or six years of life are decisive and

long-term impact on the development of a person's character.

However, the causes of emotional distress can be not only in

traumatic events in early childhood, such as

early loss of mother or dysfunctional relationships in the family, but

and/or in later life events. Past Childhood Events

are only important if they interfere with the ability

A therapist of any school who promises healing for a specific and

quite a short period of time - not fair.

16. When can psychoanalysis be considered complete?
Therapy is considered complete when the patient's goals

achieved. When the patient is able to comfortably experience everything,

what he feels - both good and bad; when he is able

adequately include all these feelings in the relationship with the analyst (i.e.

understand and analyze). when feelings do not interfere, but

help in achieving his own interests and goals - therapy

completed.
17. How has psychoanalysis changed since Freud?
Psychoanalytic theory and therapy have also undergone

changes since Sigmund Freud. The main focus in their

research Freud devoted to research sexual attraction, V

in particular the Oedipal phase of psychosexual development from the age of

four to six years of age when falling in love with a parent

opposite sex. After Freud, the focus

psychoanalysis was aimed at studying how the individual

enters the world precisely as an individual, possessing

self-awareness and a sense of positive self-esteem. IN

modern models of psychoanalysis also deals with aggression,

early mother-child relationship, social

relationships, family dynamics and psychosomatic problems.

Early psychoanalysis is acceptable only for the treatment of problems

neurotic patients whose roots of problems are in early childhood. At

contact between patient and analyst should be made as far as possible

more often, preferably daily. The only intervention

used by the analyst - interpretations or explanations of behavior

patient. Today, patients rarely visit

psychoanalyst. Analysts have a wide variety of

techniques to respond flexibly to the patient's behavior.

Modern Analysis dynamically changing to meet

people's needs, both the patient's expectations and the requirements

practicing analyst.
18. Are there different schools of psychoanalysis?
Since the birth of Freudian analysis in the early 1900s

years, numerous approaches have been developed, including

theoretical and practical models of K. Jung, A. Adler, K. Horney,

G. Sullivan, M. Klein, H. Kohut, and others. Each school of psychoanalysis

focuses in detail on various aspects of treatment or

personality. The differences between these schools have become smaller over time.

dramatic. Often, differences between analysts trained in

within the same tradition may be the same or even

more significant than the differences between analysts of different

schools.
19. What are the differences between psychoanalysis and other

forms of therapy?
There are literally hundreds of types of psychotherapy available to all, and

it would be helpful to understand something about each of them before

choice of therapist. Unfortunately, much of what has been

written or said regarding psychoanalysis, has been said

people with little experience and knowledge about modern modifications

psychoanalysis. However, there are still some basic

features that distinguish psychoanalysis from other forms of psychotherapy:

The psychoanalyst prefers to treat patients without

the use of drugs, although on occasion he may in cooperation

with a psychiatrist to prescribe medications used for treatment

depression, psychosis, or underlying anxiety.

The psychoanalyst does not give clear and specific recommendations

(advice) on how the patient should manage their

life or solve their problems. On the contrary, the analyst helps

the patient to understand why he is unable to decide his life

problems or what internal conflict deprives him of orientation,

how to act in certain circumstances.

When necessary, the analyst can delay solving problems

until a later date, or may act decisively and quickly,

to protect the patient from harm or sabotage of treatment.

20. Is psychoanalysis just a fad or outdated

therapy technique?

Some social circles believe that psychoanalysis is outdated,

and the Gestalt or behavioral schools are the last

word in treatment. The truth is that psychoanalysis is not

more outdated, and no more fad than going to the dentist or

surgeon. Since the practice of psychoanalysis relied on

the early works of Sigmund Freud, a long history of psychoanalysis

brought new discoveries regarding the psyche and methods of its

treatment, which greatly enriches the ability of the therapist to help

patients.
21. Isn't psychoanalysis a kind of escape from

reality?

For the most part, during psychoanalysis, the patient relaxes.

and calms down, but the analysis can also be quite rigid

work. It often seems to relatives or friends that psychoanalysis

This is artificial support, a kind of "psychological

crutches" that it leads to an escape from reality, to

illusory avoidance of problems. In fact, the patient during the analysis

acquires a real opportunity, calmly and realistically look

in the face of life events. During analysis, he is not encouraged to be

dependent, on the contrary, he must become independent and responsible

for your destiny.

22. Can a person change himself, only at the expense of his strength

will?
A person with a strong will can certainly influence external

manifestations of emotional problems (symptoms), but as a rule, he

very often does not realize and does not notice most of them.

Of course, many people have radically changed the form and content

own life and without psychoanalysis, but the solution of emotional

problems caused by unconscious conflicts can be

adequate only through psychoanalysis.

23. Is it possible to use introspection?
Rather not, because most people have such a high

the degree of resistance that leads to the fact that

the results of introspection are either too superficial or

reinforce pre-existing beliefs about oneself, rather than

cause radical changes. Of course, some people have

sufficiently developed abilities for introspection, but without a regimen

regularly scheduled sessions, without processing information from

with the help of an experienced analyst, the information they recognize about themselves is little

useful in life. Also, a lot of who we are is

determined by our relationships with other people. Analyst

provides an opportunity to observe our typical behavior

in a fairly close relationship (between analyst and patient) and

safely model new ways in relationships with others.
24. How do you train to be a psychoanalyst?
Perhaps psychoanalysts receive the most rigorous training

of all therapists. To do analysis, the psychoanalyst

must undergo a deep personal analysis, complete

comprehensive theoretical training, and some time to lich

patients under the supervision of senior analysts (supervision). This

education is usually not available at graduate schools or

universities and usually psychoanalysts are trained in independent

specialized institutes (training institutes).

The teachers of these institutes are usually experienced analysts, and

programs are reviewed and accredited by major

psychological organizations such as ABAP or APA (American

Psychological Association).

Usually, for training in psychoanalysis, it is necessary to have

previous basic education of a psychiatrist, psychologist,

social worker, medical practitioner or lawyer, nurse,

although it is not strictly required for learning

psychoanalysis. As a result of training, analysts may also have

scientific degrees M.D. (doctor of medicine), Ph.D. (Ph.D),

M.S.W., or M.S.N. Psychoanalytic training usually lasts from

five to ten years, because the trainee after the theoretical

training must itself be analyzed, then it must deal with

supervised therapy until

the supervisor does not recognize his right and competence to engage in

analysis on your own. Unlike learning in a different kind

psychological schools, which lasts one or two

semester, analyst training continues until

supervisors, faculty, and trainee will not agree that it

fully completed.

25. How much does psychoanalytic treatment usually cost?
Fees are usually agreed upon by the patient and the therapist with the eye

by eye, but usually quite comparable with prices for other forms

psychotherapy. Sometimes the payment for psychoanalysis can be partially

reimbursed by some health insurance funds. Patients,

unable to pay standard fees to private analysts,

can get help in public psychoanalytic clinics

or find other funding sources.
26. How often do psychoanalytic sessions take place?
Freud and other classical psychoanalysts tried to

meet with their patients at least four to six times a

week. Modern therapists meet with patients less

regularly, according to the needs of the client.

27. How to choose the right psychoanalyst?
The psychoanalyst must be certified

a specialist who has a document on a completed psychoanalytic

training in an accredited educational institution. It is desirable that

he had experience in solving problems of the type experienced by

prospective patient. Once you have chosen a therapist, you

it is necessary to pass 4-6 sessions of analysis as a test

period to see if you and the therapist can work together

cooperate.

28. Does a psychoanalyst have to be male (or

woman)?

For most people, the gender of the analyst is not important. Exception

are patients who lost their parents in early childhood,

they are often advised to seek a therapist of the same gender as the lost

parent; on the contrary, people who have a strong antipathy towards

either gender is advised to avoid working with a therapist

the corresponding gender. There are quite a few theories about

how patients and analysts of various

sexes, however, these theories are usually criticized through some

time. The conclusion is very simple - the patient must choose such

therapist in whom he feels trust.

PSYCHOANALYTICAL PSYCHOTHERAPY

As synonyms for P. p. in modern literature, such concepts as “psychodynamic psychotherapy”, “insight-oriented psychotherapy”, “explorative psychotherapy” are used.
Although some psychoanalysts, notes Curtis (Curtis H. C., 1991), are of the opinion that psychoanalysis cannot be clearly distinguished from P. p., except for such quantitative factors as the number of sessions regularly scheduled over a set period of time. , and a long duration, however, comparing them in terms of the quality of the process, one can establish significant differences. Given that these distinctions may be blurred at the point where intensive psychotherapy can acquire some of the descriptive and qualitative characteristics of psychoanalysis, there still remain differences in the meaning of the patient's experience and the nature of the interaction between patient and analyst, as well as in the technical interventions that result from this experience. . Some of the differences may be related to the respective goals of these two therapeutic interventions, especially when moving from the border area to the area allocated to each of the methods.
The names themselves indicate one important parameter: therapy, not analysis. Although it is clear that the two categories are not mutually exclusive, except perhaps that at the extremes of the spectrum, the goal of therapy is to emphasize mitigation, relief, adaptation, and re-functioning. The same phenomena arise in analysis, but they are not considered as end points and are subjected to further exploration to determine their meaning and function, as the emphasis is shifted to achieving a different goal - increasing self-knowledge and the ability to constantly expand awareness of the inner mental life. In order for this process to begin, to be established and to be maintained, a special combination of technical measures is required to create the psychoanalytic situation. These techniques include: the use of free association, covering the entire psychological field, rather than focused discussion; lying position; regularly scheduled appointments 4-5 times a week; the position of the analyst, expressing empathic objectivity, tolerance and neutrality regarding the patient's reactions; refraining from participating in the patient's non-analytic life or in his transference-like behavior; response to manifestations of transference by clarification and interpretation. At different stages, these elements may vary (combine in different ways), but they form a relatively constant configuration, leading to the emergence of previously unconscious or not fully understood thoughts, feelings and fantasies, which become more accessible for insight, modification and integration into a mature personality.
Any change or non-observance of any of the elements of the psychoanalytic situation can significantly affect the nature of the material produced by the patient and the quality of the interaction with the analyst. This is especially true for the influence on the two central dynamic forces - transfer and resistance, the analysis of which can be difficult due to the deviation from the optimal balance of these main forces. specifications. Selective change in this combination of postures and procedures can contribute to either bad analysis or good psychotherapy, so it is extremely useful to have a clear understanding of the human psyche and the consequences for the patient of a particular approach, as well as technical interventions in order to select the appropriate form of psychotherapy that will prove most effective in achieving patient goals.
The main contribution of psychoanalysis, not only to psychotherapy and the field of psychiatry, but to medicine in general, is the psychodynamic way of thinking. It means taking into account the influence of unconscious psychic forces interacting dynamically with the processes of defense, affect and thinking in order to achieve adaptability, more or less adaptation. Understanding the nature and significance of these processes helps to choose treatment that meets the needs and abilities of the patient, and to understand the unique, subject to change decisions and trade-offs that each person comes to. This breadth of coverage inner world impulses, feelings and fantasies, with simultaneous tolerance and passion, allow you to listen, learn and perhaps resonate with another person in ways that are therapeutic in themselves.
In distinguishing between psychoanalysis and P. p., it should be emphasized that this is done with the aim of providing a scientific and practical system within which an informed choice of the optimal form of psychotherapy can be made. Indeed, from a purely practical and therapeutic point of view, the need to develop increasing scientific and utilitarian forms of application of psychotherapy is of paramount importance. The role of psychoanalysis in this search is analogous to laboratory research in discovering principles that can serve as a basis for the further development and practical use of psychotherapy on a large scale. Therefore, properly applied psychotherapy should not be considered second-rate or just a way out dictated by the limits of reality. Practice shows that a carefully selected form of psychotherapy can be the best treatment for certain forms of psychopathology.
The concepts of conflict and compromise are a reflection of universal mental processes, which are efforts aimed at achieving some balance that satisfies the desires and demands of all aspects of the psyche. Symptoms, character traits, dreams, transference are all compromises of varying degrees of complexity, expressing elements of desire, protection, and punishment. In any form of psychotherapy, as in any human communication, there is the potential for the form of compromise to change depending on some transformation in the relative strength of the various components. As in spontaneous, unintentional social relationships, as in scientific, planned psychotherapy, a painful, hard-to-compromise person can use interaction to feel more satisfied, less anxious, safer, free from guilt, or, conversely, condemned, punished, destitute, etc. In any case, pre-existing symptoms, traits, obstacles may become more or less intense, may disappear or be replaced. Freud (S.) had this phenomenon in mind when he said that more patients were healed by religion than would ever be cured by psychoanalysis. If the therapist is perceived as a good parent who is supportive, comforting, secure, forgiving, and generous, then the balance between the components of the compromise can shift, often toward symptomatic relief; or the doctor is able to mobilize the patient and help him use the available mental reserves or tendencies, as a result of which a new and more adaptive equilibrium is achieved. In intensive, expressive forms of psychotherapy, frequent and prolonged, the personal interaction of the patient and the therapist creates a unique opportunity for a new experience of human relations. More effective behaviors can be learned through trial and error in a safer and more permissive treatment environment, and when they are integrated through identification with the therapist, they can lead to lasting personality change.
All the changes and modifications described above also occur in psychoanalysis. An additional factor provided by analysis is the expansion of awareness into the deeper realms of conflict, while the impulses and protective forms of childhood are subjected to repeated investigations and modifications, worked out with the help of more mature, objective and affective mental processes. The selection of patients for a specific psychotherapeutic approach depends on an assessment of their need and ability to initiate various processes of change. One of the characteristics favorable to psychoanalysis is the awareness of suffering or dissatisfaction along with the desire to understand oneself through self-observation. This is usually associated with frustration tolerance and good control. In this regard, the ability to work productively and maintain relationships with others, as well as the presence of a sense of humor and metaphorical thinking, is encouraging. Usually, acute crises in the current life situation do not help a broad, consistent, self-reflective method of analysis.
With this set of characteristics as a model, one can draw up a patient profile for whom P. p. is the best option. Revolution and crisis are indications for supportive, problem-solving measures, at least until a state of relative control and calmness sets in. , allowing to assess the capabilities of the individual. Difficulties with control and frustration tolerance, often evident from work and relationship problems, are the basis for recommending supportive, educational therapy. The limited ability to reflect on one's own thoughts, feelings, and behavior is often manifested in the patient's refusal to engage in self-observation. This limitation speaks in favor of a supportive and directive type of psychotherapy, rather than one focused on insight and conflict resolution.
Factors of time, place and cost of psychotherapy can play a decisive role. In addition, different combinations of the qualities described, which are inherent in the two main types of psychotherapy, may dictate an intermediate form of psychotherapy that combines expressive and supportive features.
To illustrate these principles and how psychotherapy can selectively use certain aspects of psychoanalytic theory and technique to meet the specific needs of the patient in treatment, Curtis first describes a case involving psychoanalysis and then gives the example of P. p.
The first patient - a highly intelligent 25-year-old woman, a stage worker - despite the increase in success and recognition, began to experience feelings of depression, irritability and tension. In addition, lately she has questioned her very active sex life, marked by frequent victories over the men she met along her artistic path. These problems apparently coincided with one rather tumultuous affair with a man she seduced and with whom she later began a serious relationship. Her sexual victories were experienced as accidental and were more satisfying in terms of power over men than in a strictly sexual aspect. While her love affairs were a vehicle for her career, she did not feel that she was being used, rather she believed that she was using men for her own purposes.
Her common sense told her that the man with whom she was involved was of high quality in every sense and was a worthy candidate for marriage, which was her ultimate goal. And yet she never felt quite at ease with him, and against her will mocked him and did not trust him. Realizing that she was in danger and could lose him, and, most importantly, feeling some kind of perverse need to push him away, she began to seek help in analysis.
In her habitual manner, she began the analysis vigorously, as if she intended to overcome an illness or win a battle with a psychoanalyst. This attitude served her well for several months as she explored her history and behavior in detail. Although she felt that she could control herself better and look at herself more broadly, she understood that real awareness and change in her incomprehensible behavior was still beyond her reach. Then came a period of heightened interest in the psychoanalyst and his personal life, and she, with pleasure and at the same time with envy, attributed to him various special knowledge and achievements. These feelings soon acquired an erotic coloring, and in her behavior, at first hidden, and then clearly, a desire to seduce the doctor began to appear.
When this desire began to prevail, she often lost sight of the purpose of her analysis, and the psychoanalyst pointed out to her the similarity of her actions during the treatment process with the characteristic desire to seduce and win every man significant to her. He then suggested that it was understandable that she would be willing to resort to the tried and true method of coping with anxiety when confronted with new, threatening situations during analysis. This clarification, repeated and developed over several weeks, led to a noticeable change in her behavior. She began to have restless dreams (being chased or attacked), then she became afraid of attending analytic sessions and, entering the office, experienced anxiety and shyness. She began to dress more conservatively and became less provocative. Noticing that she began to blush often, she said that she felt like a frightened virgin.
This dramatic change - from the bold seductress to the frightened virgin - was interpreted by the psychoanalyst as the emergence of a transference neurosis, i.e., as a regressive and dystonic expression of aspects of the banished fantasies of childhood, now focused on the psychoanalyst in a revived and at the same time altered form. This affective experience is by no means identical with that of childhood, for the latter has undergone a development and transformation and is now taking place and being imprinted in the personality of an adult who is a partner in a truly therapeutic relationship. However, it should be emphasized that both major themes and specific relationships in childhood can be brought together and affectively re-experienced.
The degree and nature of transference neurosis can vary widely from patient to patient. For some, this is a vivid, exciting experience that is difficult to contain within the framework of analysis, leading to a reaction or flight. In others, it is expressed as a pale, weakened - "it is, then it is not" - an experience contained within safe limits by the protective mechanisms of the personality, which work too well. It would be more accurate to call these manifestations transference phenomena rather than transference neurosis, which suggests a more organized, stable mental structure. Sometimes the recognition of a transference neurosis can be delayed or obscured by the strong manifestation of the defensive aspect of stubbornness or apathy, rather than the more characteristic qualities of energetic impulse and affect. In other sources of information, such as dreams, fantasies, memories, or, often more importantly, in the psychoanalyst's empathic reactions or countertransference, these states of resistance can be seen as an element of transference neurosis, the more erotic or angry states are expressed. Conceptually, they represent what A. Freud (Freud A.) called the transfer of protection, since they come from protective mechanisms that have arisen in the child's attempts to establish balance and control in relation to threatening impulses.
In the case of the patient described, the anxiety state in which breathing stops and the person turns red was investigated not only with the help of the patient's dreams and associations, but also with the help of the psychoanalyst's empathic reactions. The image of the "frightened gazelle" and the sense of impatience in the psychoanalyst's reaction were key messages suggesting that the patient was struggling with a masochistic fantasy in which the doctor was cast in the role of an attacking sadist. Several different versions of this interpretation have resulted in increasingly clear manifestations of this fantasy in dreams and conscious images.
With the emergence of memories and dream elements associated with the particular house in which the patient lived at the age of five, it was possible to begin to interpret the genetic connections and reconstruct a more holistic picture of the development of her neurosis. For example, she acknowledged that the anxiety she experienced during the analytic session was identical to her childhood anxiety shortly after witnessing several sexual encounters between her parents. At first, this was expressed in the fact that she began to be afraid of her father, began to run away from him in alarm and excitement when he returned home, which made him chase her. This - good example forming a compromise in the form of a symptomatic action: her anxious flight provoked her father to chase after her. Interestingly, the patient's efforts to find a more comfortable solution to her conflict over masochistic misconceptions about the sexual role of women took on a more sublimated, rather than merely neurotic, form. As a child and feeling fear and isolation, she often indulged in romantic fantasies and played the role of the heroine of familiar fairy tales and stories. In adolescence, she overcame her shyness and anxiety and participated in school plays, which led her to the stage. Stage activity more and more satisfied and absorbed her. First, she got rid of her anxious feelings, and later she developed a defense against fear - a transition that made acting on stage more bearable. Simultaneously with these changes, however, she developed a counterphobic sexual promiscuity, which led her to psychoanalysis.
This summary of five years of analysis can serve as a paradigm for a number of additional transference themes that have been developed and explored: rivalry with big brother; hatred for a father who did not love her enough; identification with a victim mother who, in response to torment, could sadistically dominate men - all this was worked out and correlated with her need to seduce men. Relations with men, which deepened her anxious depression, could not be maintained for long; and it was only late in the analysis, after sufficient transference had been worked through, that she entered into a relationship that eventually led to marriage. This period was especially fruitful analytically, as it required a careful study of her feelings in the transference against a growing ability to understand and follow to the end her mature sexual goals, which were now freed.
An important feature of this short and concise case history is the selection of a patient with recognizable intrapsychic conflict, coupled with a personality structure with good adaptive abilities, provided a stable, safe therapeutic environment that allows the use of free association to get to mental episodes of meaning and processes from which to this patient was shielded. This is usually associated with anxiety about regression and loss of control, leading to reliance on and fixation on familiar symptoms and defense mechanisms as the first line of defense. An explanation is needed to help the patient understand some of the stereotypes and meanings of these habitual forms of behavior. As these stereotypes become less automatic and more uncomfortable, transference manifestations will become more pronounced. These will be expressions of previously repressed feelings and fantasies of childhood. The experience, observation and understanding of this mixture of revived and reactive ways of manifesting conflicting aspirations will now become the focus of analysis, and they are approached by interpreting and reconstructing their origin.
As a contrast, Curtis gives an example of psychoanalytic therapy using certain aspects of psychoanalysis, but with significant differences.
Some patients, for reasons due to reality and psychopathology, do not fit the indications for psychoanalysis. This may require a creative combination of techniques that provides support and some new interpersonal experience, whereby self-esteem and insight can be enhanced. Without creating access to unconscious dynamic and genetic factors, working for a long time with the derivatives of these conditioning elements contributes to personal growth and self-understanding.
One such patient was a 28-year-old university intern who struggled with social anxiety, academic neglect, and bouts of depression. His dissertation work was delayed by these symptoms, and on several occasions he was on the verge of being expelled. He had male friends who shared his intellectual and musical interests; He led a rather isolated life. His sex life was limited to relationships with four or five women, with whom he managed to establish no more than satisfactory sexual relations, without real intimacy. He lost hope of finding a woman who would want to marry him, because he was aware that his anxiety and distrust could cause alienation.
As you might expect, it took a lot of work for him to come for treatment. His anxiety, which had a tinge of wariness and distrust, was an immediate obstacle to psychotherapy, as well as a main, long-standing problem. Sometimes he joked darkly about her, and this convinced the psychoanalyst that this trait of his did not reach the level of paranoid disorders. Given the patient's sensitivity and reticence, the psychoanalyst concluded that he would benefit most from intensive, long-term psychotherapy that would enable him to understand and overcome his fear of being trapped or humiliated. The psychoanalyst also proposed a trial period, after which the patient, if he sees that he does not trust the doctor, has the right to stop treatment. This "emergency exit" gave the patient some sense of security, while the psychoanalyst's recommendation for intensive psychotherapy convinced him that he needed help.
Work started on schedule. Twice a week, the patient and the psychoanalyst sat face to face, exploring both the patient's daily experiences and his reactions to the psychoanalyst and psychotherapy. The first few months were clearly a trial period during which the patient sought and sometimes found confirmation of his doubts about the analyst's intentions or ability to help him; the doctor tried especially hard to watch his inner feelings and reactions, aware of the sensitivity of the patient. The psychoanalyst's errors and misunderstandings were discussed honestly, not only in order to clarify them, but also in order to understand their perception by the patient. The psychoanalyst answered the patient's questions about his vacation, office decor, car, etc., but if he considered the questions too personal or if the answer to them would interfere with psychotherapy, then he told the patient about it. He usually smiled and agreed.
The effect after the first six months of such work was expressed in the gradual weakening of the patient's alertness. He felt more confident that the psychoanalyst would not allow himself to attack him, would not try to use his words against him and dominate him. Now he could reveal to the psychoanalyst some of his secrets, fantasies, and painful childhood memories. The increased trust in the analyst, based on the experience of dealing with him in the process of open investigation and understanding of the events occurring within this experience, was further strengthened by the fact that the patient now associated his distrust with the traumas and resentments that he remembered. Since the psychotherapeutic approach did not produce material that would reveal the projections and transformations of his traumatic experiences, the psychoanalyst was content to create a coherent picture of his life up to the present. Symptomatic improvement, increased self-confidence - all this made it possible for the patient to complete his dissertation. His relationships with women became freer and more intimate, and he apparently intended to marry when the psychoanalyst spoke to him for the last time.
This therapy lasted three years and consisted of two main elements. The first is what Bibring (Bibring E., 1954) called "empirical manipulation", in which the patient is given the opportunity, within and outside of treatment, to gain new experience that can have a mutational effect. This can be done in a permissive, encouraging atmosphere of therapy and with the help of transference. In this case, transference was not analyzed, as in psychoanalysis, although the transference experience was discussed and used to clarify the ways in which the patient can build his relationship with the psychotherapist and other people.
The second technically important element is the clarification of the patterns of the patient's behavior and their origin from past developmental influences. Such a reconstruction differs from that carried out in psychoanalysis in that it lacks the parameter of unconscious conflict and fantasy explicitly integrated into this conflict. However, reconstruction can provide a sense of permanence and stability and self-understanding, which has a stabilizing effect.
Based on the psychoanalytic principles and concepts of mental functioning reviewed and the clinical examples presented, Curtis made some basic technical recommendations for P. p.:
1) identify crucial dynamic issues to localize and limit the therapeutic actions being taken;
2) do not touch on aspects of the personality that are not closely related to the central problem;
3) focus on the patient's current relationships and personality defenses;
4) support the patient's adaptive skills and resources;
5) create a stable, receptive atmosphere of support and respect;
6) encourage more adaptive ways of eliminating painful symptoms through new movements and identifications.
At the stage when the patient shows a permanent improvement, the question of the end of treatment should be considered. The limited goals of psychotherapy require that regression to dependency on the therapist be controlled by supporting and encouraging the patient to pursue independent behavior. Evidence of an increased ability to function independently should be recognized as a commendable achievement, the patient's desire to stop treatment is usually accompanied by anxiety, which can be reduced by the therapist's recognition and belief in the patient's ability to maintain the improvement achieved.
See also DYNAMIC DIRECTION IN PSYCHOTHERAPY, CLASSICAL PSYCHOANALYSIS.

Psychotherapeutic encyclopedia. - St. Petersburg: Peter. B. D. Karvasarsky. 2000 .

The use of psychoanalysis in psychotherapy

1. The main provisions of psychoanalytic therapy, as a therapy focused on psychoanalysis

1.1 Focus of psychoanalytic therapy

Psychoanalytic psychotherapy mainly focuses on the impact of past experience on the formation of such a specific behavior - through special cognitive abilities (defenses), interpersonal interaction and perception of a communication partner (transfer) - which has acquired constant repetition and thus affects health. patient.

Table 1

Focus - The impact of past experience (cognitive abilities, affects, fantasies and actions) Goal - Understanding the functioning of the patient's defense mechanisms and transference reactions, in particular, in the form in which they manifest themselves in the course of communication between the patient and the therapist

The past of the individual exists in his present, thanks to memory and biology. The expected prediction of the present and future is formed on the basis of experience, past and biology. In the same way, the patient's metaphorical language may reflect some special organization (a set of feelings, thoughts and behaviors) formed in the past and affecting his current abilities, perceptions and behavior. By exploring the present meaning of events in the context of the past, the psychotherapist-psychoanalyst seeks to change these "organizing systems" of his behavior, helping to ensure that information and experience are organized differently in the future. Psychoanalytic psychotherapy is based on the principles of the functioning of the psyche and psychotherapeutic techniques originally developed by Sigmund Freud. Freud began his work with hypnosis, but later came to free association as a method of understanding the unknown unconscious conflicts that arose in the course of human development, starting from childhood, and continued into adult life. Such conflicts are those behaviors that were laid down as clusters of feelings, thoughts and actions. They arose as a result of the interaction of various events in the individual developmental history of a person with a biological predisposition.

Usually such unconscious conflicts arise either between libidinal or aggressive desires (drives) and fear of loss, fear of retribution and limitations determined by reality, or in a clash of opposite desires.

"Neurotic" conflict can lead to anxiety, depression and somatic symptoms, stunted professional and social growth, sexual difficulties, and interpersonal relationships that make adjustment difficult. Such unconscious neurotic conflicts manifest themselves quite obviously as the patient's manner of behaving, feeling, thinking, fantasizing and acting. Perceived in childhood, they may correspond to the patient's childish view of the world around them, be adaptive and even necessary for survival in a certain period. Even if these conflicts are not initially recognized by the patient, in the course of psychotherapeutic work they come to the surface, and many of their consequences become more obvious.

Psychodynamic psychotherapy can be short-term and long-term. Treatment can last for months or even years. Freud noted that working with the unconscious requires continuity, regularity and stability. From this position follow his recommendations regarding the spatial and temporal organization of the therapeutic environment. Long-term treatment, in fact a date, does not have a fixed end, and the end date is difficult to set at the beginning of the treatment process. The duration of treatment depends on the number of conflict zones that must be worked out during such treatment. Psychotherapy sessions are usually held two to three times a week, although for short-term treatment, one session per week is the usual norm. More frequent meetings with the doctor allow him to penetrate deeper into the inner life of his patient and lead to a more complete development of the transference. Frequent meetings also support the patient throughout the treatment period.

1.2 Basic techniques of psychoanalytic therapy

In our work, we will consider some psychoanalytic techniques, namely the working alliance, the method of free association, transfer, interpretation.

Working Alliance.Behavioral change occurs in psychodynamic psychotherapy through two processes: the understanding of cognitive and affective processes emanating from childhood (defense mechanisms), as well as the understanding of the conflict relations formed in the patient with the most important objects in childhood, and their resurrection in the relationship with the therapist (transfer). Diagnosis of understanding such feelings and perceptions is the focus of treatment. The treatment environment should be organized in such a way as to make it as easy as possible to bring these phenomena to the surface, and in such a way as to make it possible to analyze them without mixing them with the reality of the relationship between the patient and the doctor and not dismissing them as something trivial.

A necessary initial condition for success in psychoanalytically oriented psychotherapy is the patient's own need to take part in such work and his confidence in his relationship with his therapist. R. Greenson gives this component the name "working alliance". The working alliance is manifested in the patient's willingness to follow the rules of psychoanalytic procedure and cooperate with the analyst. Such an alliance is built on the realities of treatment - working together to achieve a common goal, as well as the constancy and reliability of the therapist. It is only in contrast to the established therapeutic alliance that the patient can view his transference feelings and become aware of the relationship distortions that these feelings bring. It is important to note that what the patient brings to be considered in psychotherapy is the main focus of treatment. The depth of interpretation and research should always be at the level of the patient's momentary needs, not to lag behind and not to get ahead of his thoughts and feelings.

Free associations. Free association method- a psychoanalytic procedure for studying the unconscious, during which the client freely speaks about everything that comes to mind, no matter how absurd or obscene it may seem. Free association of the patient should be encouraged. This is achieved in a very simple way. The patient is told that he is free to talk about anything. The main task of the therapist in this case is to listen to the deep currents of the patient's associations. This implies understanding the connection of one story with another, identifying the patient's attitude to the person he is talking about, paying attention to the impressions that the patient has about his doctor. Often, hearing some ambiguity in the patient's associations, the therapist can open the way to an unconscious conflict and a significant person from the patient's past with whom this conflict is associated.

« For example, a patient comes to see a psychotherapist immediately after an argument with his girlfriend and says, "I want her back." If you catch the double meaning here in the sentence - to be with her again or to get her back in order to take revenge on her - then you are unlikely to be surprised to hear that, although the patient said at the beginning that he wanted to be with her again. his girlfriend, by the end of the session he is already describing his fantastic retribution. (His fantasy was borrowed from an old movie. He fantasized about the pleasure with which he would smear a grapefruit on the girl's face.) Conflicting feelings - longing for her and a feeling of hatred - are already indicated at the beginning of the session. This usual pattern of reaction to rejection developed for him in his childhood relationship with his mother, who probably experienced the same conflicting feelings for him and once drove him out of the house at knifepoint. Of course, he was not yet ready to hear about such a connection, but it was already becoming quite obvious. This "pattern" could now be observed and guided the patient along the path of gradual, slow awareness. .

Transfer (Transfer).In psychoanalytic psychotherapy, one of the most important tools in the hands of the therapist is the development and understanding of transference. Transfer (transfer) is an unconscious reproduction by the patient in the relationship "here and now" of early experience of relationships with significant people from his environment. Thus, feelings and impulses of past conflicts are projected onto a real person in the present (for example, a psychoanalyst). Transference is a wave from the past that overwhelms the present and leaves traces that cannot be confused with anything. Transference is the driving force behind the process by which the patient's difficulties "come to life and materialize" in the therapist's office, allowing for a deep examination of what they are and how they are realized in his real and significant environment. In fact, this is what distinguishes psychodynamic psychotherapy from all other forms of psychotherapy more than anything else, namely understanding the transference and analyzing it, rather than simply trying to overcome it.

One way to understand the concept of transference is to imagine that the human brain is partly made up of sets of memories of each of the important personalities from a given person's past. Such organized sets of memories are called "object representations" and when a person meets another, unfamiliar person, he or she begins to form a new object representation. Needless to say, such a process begins and is carried out to a certain extent only when a new person is of interest to the observer, but when such a process begins, the observer, trying to understand his new acquaintance, begins to rummage through his memory in search of those standards that allowed to evaluate and compare the new individual. Soon, both old and new object representations are psychologically linked, responding to the observer's need for familiarity or some other psychological need. The stranger is studied through ideas, thoughts, and feelings that were originally intended for an old friend, relative, loved one, or enemy.

Much of human psychic activity is aimed at keeping the unconscious beyond the conscious with the help of a special way of thinking. Due to the fact that the transference usually brings to life long forgotten, conflicting aspects of the relationship, very often the patient seeks to reject the feelings, thoughts and memories contained in them and, at the same time, rejects the psychodynamic psychotherapist and generally tries to interrupt the therapy. Such resistant transfer ideas must be understood in order to use transfer effectively to achieve a successful treatment outcome.

Interpretations.The objects of interpretation can be: transference, external reality, the past experience of the patient and his defense mechanisms.

Kernberg distinguishes clarification, confrontation and interpretation proper in the process of interpretation. The first step in interpretation is clarification. It is an invitation to the patient to explore material that appears nebulous, mysterious, or contradictory. Clarification has two goals - to clarify certain data and to assess to what extent the patient is able to realize them. At this stage, the analyst turns to the conscious and preconscious levels of the psyche. Technically, the clarification procedure looks something like this: the psychoanalyst selects one of the aspects of the patient's verbal or non-verbal behavior in the session, focuses his attention on it and offers it as material for association. As a result, new, hitherto unexplained phenomena come into the field of analysis.

Kernberg gives a number of examples of the clarification technique:

a) “I have noticed that whenever I move my chair, you glance at your watch anxiously. Do you have any thoughts on this?" (transfer clarification);

b) “You keep repeating that any woman in your place would do the same as you, and that you do not see anything special in your feeling of disgust for men. Could you explain your point of view?” (clarification of the alleged defense mechanism).

The second step in the interpretation process is confrontation. It brings the patient to the realization of contradictory and inconsistent aspects of the associative material, draws his attention to facts that were not previously realized by him or were considered self-evident, but at the same time contradict his other ideas, views or actions. In the process of confrontation, the analyst can relate the material of the current session to external events in the patient's life, thereby revealing the possible connection of the therapeutic relationship "here and now" with his other interpersonal relationships. The object of confrontation, as well as clarification, can be transference, external reality, the past experience of the patient and his defense. Here are examples of confrontation:

a) “You rejected without hesitation all the considerations expressed by me during today's session, and at the same time repeated several times that you did not receive anything from me today. What do you think about it?" (confrontation relating to transference);

b) “There is a feeling that the desire to find another woman appears in you every time you unexpectedly discover traits that you like in the character of your partner” (confrontation related to defenses).

Like the clarification stage, the confrontation addresses the conscious and preconscious levels of the patient's psyche, setting the stage for interpretation. Interpretation completes a single interpretative cycle by linking the patient's conscious and preconscious material to putative unconscious determinants. Its goal is to achieve a therapeutic effect by bringing to the patient's consciousness his unconscious motives and defenses and thereby removing the inconsistency of the material reported by him. Interpretation is a psychoanalytic device, the most profound in its impact on the patient.

The analyst can interpret transference, external reality, the patient's past experiences and defenses, and link all of these observations to the patient's supposed unconscious past experiences (such interpretations are called genetic interpretations). Let's look at some examples:

a) “It seems to me that you are trying to provoke me into an argument with you in order to drive away sexual fantasies about me. What do you think about it?" (transfer interpretation);

b) “Perhaps your attempts to deny the presence of hidden attacks on you in the speech of your political opponent indicate how much you are afraid of the intensity of your own hatred for him” (interpretation of the defenses);

The main principles of psychoanalytic interpretation include the following:

First of all, you should interpret the material that prevails in this session. The analyst, however, should only interpret when, in his opinion, the patient is unable to do so on his own.

First, the material that is closer to consciousness is interpreted, and then - deeper, less conscious. In accordance with this principle, the psychoanalyst first interprets the defenses and only then the content hidden behind them.

In interpreting the fact that the patient is not aware of anything, the analyst must include in his interpretation an indication of the possible motives for this defensive "unawareness". By offering the patient an explanation of why he resorts to such a defense, the analyst thereby helps him to accept this content that he rejected.

The interpretation must include a description of the conflictual nature of the patient's mental dynamics.

The psychoanalyst should only interpret under the following conditions:

a) he is able to more or less clearly formulate an assumption about what is behind the patient's statement;

b) he is sufficiently sure that if the patient agrees with this assumption, the level of self-consciousness of the latter will increase; if the interpretation turns out to be wrong, it will still serve to clarify the situation;

c) it seems unlikely that the patient will be able to come to this conclusion on his own, without the aid of the analyst's interpretations.

Until all three of these conditions are met, the psychoanalyst either remains silent or confines himself to using the techniques of clarification and confrontation. When they occur, they should be interpreted as soon as possible.

1.3 Indications and contraindications

Psychoanalytic psychotherapy uses specific techniques and a particular understanding of mental functioning to select and deliver appropriate interventions on the part of the therapist. As with other types of treatment, there are indications and contraindications.

Psychodynamic psychotherapy achieves better results with mental disorders of the "neurotic" level. The roots of such conflicts, as a rule, lie in the "oedipal complex", and the patient usually experiences them as "internal". These are obsessive-compulsive disorders, anxiety disorders, conversion disorders, psychogenic somatic illnesses, dysthymia, mild to moderate affective disorders, adjustment disorders, and mild to moderate personality disorders. Those patients who are able to think in psychological terms, to observe feelings without reacting to them in action, who are able to achieve relief of symptoms through understanding, can receive great help from psychodynamic psychotherapy. The patient who is in an environment that can support him in the family, with friends, at work - usually achieves greater success, as he uses therapy more effectively. Such a patient does not need a therapist as an initial source of support under the stresses of life or treatment. Patients with more serious illnesses such as severe depression, schizophrenia or borderline personality disorder can also be treated with psychodynamic psychotherapy. For such patients, treatment is usually aimed at modifying the factors that caused the disease, better adjustment, getting rid of symptoms and returning them to normal life. Patients with severe "preoedipal" pathology cannot be considered suitable candidates for treatment with psychodynamic psychotherapy. This is manifested in their inability to form mutually supportive dyadic relationships, their preference for exploitative relationships in a chaotic lifestyle, real (and even dangerous) emotional reactions. The main requirements of psychodynamic psychotherapy - that the patient must have a strong observing ego and the ability to establish a mutually supportive therapeutic relationship - such patients cannot afford

Freud believed that since psychotic patients are essentially narcissistic, they cannot be treated by psychoanalysis, since they cannot develop a transference neurosis. The division remains in place, but today many patients who cannot be neatly assigned to one category or the other because they have features of both neurosis and psychosis are treated in this way. Moreover, at the present time some analysts find it possible to carry out classical analysis with psychotics and achieve good therapeutic results. . Most analysts, however, are of the opinion that narcissistically fixed patients require changes in standard psychoanalytic procedure.

2. Kohut's contribution to the modern development of psychoanalytic psychotherapy

.1 Kohut's main ideas in the theoretical construction of the psychology of the self

Kohut developed an aspect of Freud's concept of narcissism that allowed him to completely move away from drive theory and strongly put forward a theory of the "I". Before Kohut, narcissism was considered a pathological condition in which a person - like the mythical Narcissus admiring his reflection in a forest lake - considers his body and his personality as the center of the universe and the only criterion of value. We all know people who talk only about themselves or their experiences, without attaching any importance to the thoughts and feelings of others. Kohut realized that such a state is an aberration (distortion) in the essence of the normal process and that going through a period of narcissism is a necessary and healthy stage of growing up. Every infant and young child should feel like the center of the universe, at least for a while. The resulting emptiness will cause a narcissistic desire for attention, which later becomes a personality defect only when this feeling is denied. Kohut saw that normal narcissism forms the core of the self.

According to Kohut, there are three strong needs that must be satisfied if the self is to develop fully: the need to "reflect" (to be reflected in another person), the need to idealize, and the need to be like others.

Kohut called these reflective and idealized people I-objects (objects of the Self), because it seems to the child that they are an extension of himself. Over time, the child will internalize relations with self-objects in such a way that he will be able to carry out the operations of reflection and idealization within himself. When these two processes of internalization are successful, they form the basis of the bipolar self. The internal process of reflection leads to realistic aspirations in the world, reinforced by the mother's internalized stimulating praise. Equally, when the idealized father is internalized, the child may aim at realistic ideals. These two poles form the core of a healthy self and generate felt aspirations and ideals that provide a sense of purpose and meaning. Kohut called the third need of the developing self "similarity" or "twinship", or the need for an alter ego.

According to H. Kohut, if the above needs are adequately satisfied, the child develops a healthy Self, which entails high self-esteem, well-functioning management of the system of ideals and values, and confidence in the development of their own abilities. If these needs are not satisfied enough, then the self will be found to be flawed, which will interfere with healthy development and create life problems. H. Kohut called these problems self-disorders.

Kohut defines Self, as a psychological structure through which the experience of oneself acquires coherence and continuity in time, thanks to which the experience of the self takes on its characteristic and stable organization, and which relates to the structure of the individual's experience of himself. This self is built of "structures" that result from transformative internalization. In accordance with Kohut's formulation, the self is bipolar in nature, consists of two main components - core ambitions and guiding ideals - arising from the transformation and internalization in the process of development, respectively, of the mirroring and idealizing functions of the object of the self. Ambition pushes us forward, and ideals point the way. In a child at an early stage, both poles are still combined due to exhibitionistic omnipotence and voyeuristic perfection, that is, a child at the stage of grandiosity. Parents should allow the child to go through this stage normally, without fixations and injuries. According to Kohut, “if traces of ambition and idealized goals begin to be acquired in parallel in early infancy, then the main part of nuclear grandiosity is combined into nuclear ambitions in early childhood (perhaps primarily in the second, third and fourth years of life), and the main part of nuclear idealized goals structures are acquired in late childhood (perhaps primarily in the fourth, fifth and sixth years of life).

It is believed that between these two poles of the Self, a constant current of psychological activity is established, metaphorically described as an "arc of tension." This arc of tension is considered a source of motivation for the basic life aspirations of the individual. Compared with the theory of drives and the structural theory of psychoanalysis, the innovation of the psychology of the Self, - L. Koehler believes, - lies in the fact that the Self and the so-called need for an object of the Self are considered within this psychological system as the main factor of motivation. The possibilities of analysis and psychological processing of many transference phenomena increase significantly if they are considered as an expression of the need for an object of the Self, and not as a consequence of impulsive desires. The Self-Object is the object without which it is impossible to maintain self-regulation. The object of the Self is perceived as a part of oneself, as a part of one's own body, for example, a hand.

If the classical theory of psychoanalysis says that in the course of psychological evolution narcissism is transformed into love for an object, the feeling of symbiosis is replaced by autonomous ideas about oneself and object ideas, then, according to the psychology of the Self, in parallel with the formation of these ideas, the evolution of the Self and objects of the Self continues, during which archaic forms are replaced by mature forms. The objects of the Self retain their functional significance throughout life and are necessary for the maintenance of normal mental content. According to the psychology of the Self, the goal of psychotherapy is to help the patient get rid of the feeling of fusion or symbiosis and not only to throw off the shackles of emotional dependence on the object and achieve stability in the relationship with the object, but also to form a more mature object relationship to himself. As a result, the patient's Self becomes more stable, his capacity for empathy increases, due to which he is able to calmly accept the fact that the initiative comes from the object itself.

2.2 Analysis of the analytic technique of transference work as a therapeutic work with narcissistic disorders

According to Kohut, patients with narcissistic personality disorders are subject to psychoanalytic treatment. Features of the self-experience of people with a narcissistic diagnosis include "feelings of vague falseness, shame, envy, emptiness or incompleteness, ugliness and inferiority, or their compensatory opposites - self-assertion, self-respect, contempt, defensive self-sufficiency, vanity and superiority" .

Instead of being overwhelmed by raging primitive introjects, these people complain of emptiness - more of the absence of internal objects than of being engulfed by them. “These people,” writes N. McWilliams, “turned to therapy in order to find the meaning of life. They were deprived of a sense of inner direction and reliable guiding values.

Narcissistically structured people are at some level aware of their psychological characteristics. They are afraid of separation, a sharp loss of self-respect, self-responsibility. they feel that their identity is too fragile not to crumble and withstand some tension.

H. Kohut, working with people who are waging a desperate struggle with inner emptiness, and not being satisfied with the Freudian psychoanalytic diagnosis of repressed sexual and aggressive energy, concluded that such patients suffer from insufficient development of the "I". He writes: "...despite the initial vagueness of the present symptomatology, most of the important symptomatic features can, as a rule, be clearly recognized in the process of analysis, especially when one of the forms of narcissistic transference is established" .

H. Kohut focused his research and therapeutic developments on understanding the nature of narcissistic transferences and the technique of working with them. H. Kohut thinks in terms of several subtypes of self-object transference that occur in narcissistic patients, namely mirror, twin, and alter ego patterns.

So, H. Kohut “divided the transferences of the I-object into three groups:

the damaged pole of ambition tries to evoke affirmative-approving reactions of the self-object (mirror transfer);

the damaged plus of ideals seeks the I-object that approves of its idealization (idealizing transference);

the damaged intermediate area of ​​talents and skills is looking for a self-object that will make itself available to a confirming experience of significant similarity (twin transference or alter ego transference).

In the "mirror" transfer, three levels are distinguished in accordance with the three levels of regression. The most archaic is the level of "fusion" or "acquisition", where the grandiose I spreads to the analyst, it seems to envelop him. Less archaic is the "Alter Ego" or "double" level. The least archaic form is the "mirror" transfer in the narrow sense. The fragility of the grandiose self requires empathy and the normal "mirror" functions of the mother as a self-object. Her love and devotion allow the grandiose self to consolidate at first, and later develop into more mature forms of self-respect and self-confidence through less and less archaic types of “mirrors”. At the same time, optimal relations with the “reflecting” Self-object contribute to the development of the normal idealization of the Self-object, which replaces the original perfection of the grandiose Self, which is now partially preserved in relation to such an idealized Self-object. Such idealization eventually culminates, according to Kohut's terminology, in the "transformative internalization" of the idealized self-object into an intrapsychic structure that gives rise to the ego-ideal and super-ego capacity for idealization, which preserves a new type of internalized regulation of self-esteem.

Kohut considers narcissistic pathology as a consequence of traumatic weakness of maternal empathy and disturbances in the development of idealization processes. “The balance of primary narcissism is disturbed by the inevitable lack of maternal care, but the child replenishes the former sense of perfection by a) forming a grandiose and exhibitionistic image of himself - a grandiose self, and b) endowing the former perfection with an admirable, omnipotent (transitional) object of the self: the idealized parental imago” . These configurations of experience are available for study and research in analysis, and as a result of proper elaboration, they can be transformed and softened.

In the course of analysis, the psychoanalyst should be allowed to develop a narcissistic idealization and not be destroyed by interpretation. This allows the mirror transference to gradually develop as well. The psychoanalyst becomes an I-object, providing a process of transformative internalization. He needs to be empathic, focusing on the patient's narcissistic needs and frustrations rather than the conflicts that cause those frustrations. Weakness of empathy on the part of the analyst leads to partial fragmentation of the grandiose self, narcissistic anger, diffuse anxiety, hypochondriasis, and even more severe states of depersonalization and pathological regression with cold paranoid grandiosity. In each such case, the analyst explores with the patient when and how the former did not show empathy and how this relates to traumatic situations in the patient's past.

Kohut emphatically emphasizes that this does not require setting the parameters of the technique. It is only a modification of the standard psychoanalytic technique, differing from the analysis of non-narcissistic patients only in that it emphasizes empathy - as opposed to "objective neutrality" - and focuses on changes in the self, rather than drives and (as yet non-existent) interstructural conflicts. In the technique of narcissistic gratification he described, one can clearly see "... liberation from the fetters of the rules of abstinence." In essence, Kohut advocated the principle of security. Its proponents point out that the frequent negative therapeutic outcome with the standard technique reflects a lack of psychotherapeutic support. Given the limited resources of the Ego and the lack of support, it is extremely difficult for the patient to work out transfer options. “Because of the devaluing and exploitative maternal attitudes in the past, the patient chronically feels his “badness and worthlessness”. Narcissistic anger is a defense to regulate self-esteem. Confrontation with hostility and envy only reinforces the initial feeling of "badness". With a weak realistic basis of the therapeutic relationship and a pronounced structural deficit, confrontation results in an "unbearable balance of goodness", "badness" and "power" (Epstein L., 1979)" . The processing of narcissistic anger in the transference does not lead to intrapsychic integration, but only confirms the "badness at all". Severe narcissistic patients are only able to accept and trust positive feedback that is perceived as a response to their efforts to "be good."

It is empathic understanding that allows anger to be softened and calmed, as it should be done in early childhood. The responsiveness of the analyst, by making up for the lack of empathy on the part of the mother figure, promotes transmuting microinternalizations. The correction of structural defects occurs due to the gradual acceptance by the patient of the functions of the therapist as the Self-object for the regulation of anger and understanding of narcissistic needs.

In therapy, Kohut distinguished 6 stages:

Stage of strong resistance;

The phase of oedipal experiences in the traditional sense, dominated by experiences of severe castration anxiety (oedipal complex);

Resumption of strong resistance. Called like this:

increased anxiety;

re-experiencing previous development;

fear of the next step.

Stage of disintegrative anxiety. Here we can reach a new stage from which a new development is possible.

Stage of moderate anxiety. The analyst must be prepared to dive into psychotic anxieties. Disintegration anxiety decreases, the joyful expectation of a new development persists, this new development begins;

Normal passage through the oedipal stage.

The process of analysis can move in a V-shaped arc, or in a spiral, necessarily with access to a new round of development.

Kohut describes therapy as a loop, that is, we go from the pathological experience of the Oedipal period, which formed the Oedipus complex, we go down and down, until the period of formation of the archaic self (the fourth stage), starting from the platform of the archaic self, we go up again. The transference neurosis is constantly growing. Then the process of normal separation begins (the analyst begins to slowly “let go” of the patient). The processes of revealing internal potentials begin, the patient begins to acquire and feel all the new abilities of autonomous functioning. It ends with the patient entering the oedipal period, which is experienced as a joyful, non-traumatic, hopeful event and a new life.

Criticism of the theory and therapeutic guidelines of Kohut is primarily carried out by O. Kernberg. In his opinion, Kohut does not distinguish between normal and pathological types of transference idealization. He also does not share the concepts of "separateness" and "differentness"; the former, according to Kernberg, is absent in schizophrenic patients, and the latter in narcissistic patients. The main thing is that H. Kohut does not distinguish between the normal grandiose I in childhood and the pathological grandiose I. Kernberg considers it wrong that Kohut rejects the interpretation of the negative transference and even artificially strengthens the idealization in the transference. In his opinion, Kohut's supportive, reeducational approach to narcissistic patients helps them rationalize their aggressive responses as a natural result of the unfortunate actions of others in their past. At the same time, there is no radical reorganization of the unconscious past through the processing of transfer neurosis.

The essence of criticism follows from various opposing positions. Kohut considered pathological narcissism in terms of development (the patient's maturation proceeded normally and met with some difficulties in resolving the normal needs of idealization and de-idealization). Kernberg, on the contrary, understood it in terms of structure (something went wrong very early in allowing the individual to surround himself with primitive defenses that differ from the norm in quality rather than in degree). The concept of Kohut's narcissistic personality can be illustrated by the image of a plant whose growth was stunted as a result of insufficient watering and lighting at critical times. Narcissus Kernberg can be thought of as a plant that has mutated into a hybrid. The takeaway from these various theories is that some approaches to narcissism emphasize the need to give the plant enough water and sun to finally grow, while others suggest that deviant parts must be pruned out so that the plant can become what it should be. . Thus, self-psychologists recommend a benevolent acceptance of idealization or devaluation and unwavering empathy with the patient's experiences. Kernberg advocates a tactful but persistent confrontation with grandiosity, appropriated or projected, and a systematic interpretation of defenses against envy and greed. Self-oriented therapists try to stay inside the patient's subjective experience. Analysts influenced by ego psychology and object relations theory, on the other hand, vacillate between an inward and an outward position.

As already noted, H. Kohut believed that the basis of a mental disorder is not a conflict, but a lack of emotional warmth in early childhood, which can and should be compensated for in the relationship between the patient and the analyst. At the same time, the psychoanalyst is not forbidden to admire the patient and show him respect.

Kohut believed that it was the therapist's job to provide corrective emotional experience and that empathy was the main component of such experience.

On the basis of empathic understanding, the patient's inner state can be explained in terms of his narcissistic needs and developmental frustrations, especially in relation to archaic states of the self. “Through his experiences in the course of the analysis, the patient comes to realize the separation between himself and the analyst; awareness that arises with the help of appropriate "non-traumatic frustrations" carried out by the psychoanalyst. This leads to what H. Kohut calls "transmuting internalization" in the patient (that is, a structural change), as a result of which the ability of the latter to take on and perform important functions of a self-object is enhanced. Progress in treatment seems to be based on the systematic working through of the process of narcissistic connection, which eventually moves the figure of the analyst from the status of a self-object or partial object to the status of a separate person with his own real traits and shortcomings.

Thus, an essential role in H. Kohut's technique of psychology of the Self is played by the analyst's empathy. Moreover, Kohut argued that the essence of empathy can only be grasped in the context of the psychology of the Self. It is seen as an important way to achieve an understanding of the internal state of the patient. Based on the theory of psychology of the Self, the analyst is able to achieve such a high empathy for the experience of the analysand that he feels himself a part of him, and vice versa.

“In the process of analysis, only the psychic, inner reality of the patient matters, which is known only with the help of empathy, that is, substitutional introspection. An objective and neutral position allows only assessing the patient's experiences from the point of view of an outside observer, and not opening them from the inside.

H. Kohut writes: “The best definition of empathy is to look at it as the ability to understand and feel oneself in the context of the inner life of another person. It represents our lifetime opportunity to experience what another person experiences, however, as a rule ... in a weakened degree.

G. Etchegoen and other critics believe that “in order to preserve the empathic connection, Kohut refused those interpretations in which the analysand could “feel” hostility and threat. Apparently, the desire to maintain an empathic climate under any circumstances had a serious impact on Kohut's views, forcing him to almost completely abandon the theory of conflict and momentum. When empathy is understood mainly as a way to protect the patient from the painful truth about himself, the scope of this concept becomes extremely narrow. Kohut does not reject interpretations in which the analysand feels hostility. In response to these remarks, we would like to respond with the words of Kohut: “... any interpretation or reconstruction consists of two stages: first, the analysand must realize that he has been understood, and only then, in the second stage, the analyst will demonstrate to the analysand certain dynamic and genetic factors explaining the psychological content that he first grasped empathically. According to Kohut, the first thing every therapist must do is open himself to an empathic experience that allows him to see the world from the client's point of view. The next task is to let know that the therapist really understands him. Michael Kahn wrote: "The first thing that sets Kohut apart from other therapists is the focus on allowing clients to know that you are doing everything in your power to understand his, the client's, views." (3, 64)

Already in his first works, Kohut argued that “psychological facts are collected only through introspection or empathy. This, according to G. Etchegoen, was a revolutionary innovation: empathy was recognized not only as a prerequisite for analytical work (which had been known since the time of Ferenczi), but the very essence of the method. Kohut has given empathy a methodological carte blanche.

In our opinion, Kohut is indebted to two points of view on empathy. First of all, Kohut identified empathy as a way of observing and collecting data. This idea is also clearly expressed in his definition of psychoanalysis as a discipline that bases its observations on introspection and empathy (transformative introspection). Kohut believed that empathy allows the therapist to experience the experience of the other without losing the ability to objectively assess the other's mental states. In addition, Kohut considered empathy to be a universal developmental need. The infant's experience of the caregiver's empathic mirroring is a necessary component in the development of the Self, and, conversely, traumatic failures in providing empathic mirroring play a critical role in the development of defects and pathology of the Self.

Conclusion

Over the past 100 years, psychoanalysis has become much more complex, new analytical concepts and entire schools have arisen. Psychoanalytic psychotherapy, as a psychotherapy based on psychoanalysis, has now expanded the categories of patients it can help.

Using the example of Heinz Kohut's theory of the development of the Self, we have shown that psychoanalytic theory develops, expanding the possibilities of psychoanalytic psychotherapy.

Kohut began to consider narcissism not only as something pathological, but also as an independent line in normal development. Kohut focused on three strong needs that must be satisfied if the Self is to develop fully: the need to "reflect" (to be reflected in another person), the need to idealize, and the need to be like others. The structures that make up the Self build up gradually through transmuted internalizations. When parents are more supportive because they reflect idealized images and alter egos, their inevitable failures allow children to provide these functions for themselves.

Patients experience difficulty because their parents have failed to provide their children with some (or all) of these features. Therefore, the therapeutic task is to enable the patient to build those structures that did not develop in him in childhood.

According to H. Kohut, the structures of the Self are built in therapy in the same way as they were built at an early age. If the analyst is mostly empathic, then conditions are created for building structures. Failure is inevitable. The analyst may be in a bad mood or distracted, or simply lose the thread of the patient's story, and so on. If the current errors are not too frequent, not traumatic, and the analyst acknowledges them with empathy and without security, then again it is possible to provide empathy without outside help. In successful therapy, structures are built gradually until the initial deficit is exhausted or until adequate compensatory systems are established.

Kohut discovered narcissistic types of transference, described them and developed an analytical technique for working with them. This marked the beginning of a new era in psychoanalysis, as the spectrum of psychopathology in which psychoanalysis was now effective expanded dramatically. He found that defects in the structure of the Self in narcissistic patients become apparent in three situations of transference: in mirroring transference, the patient tries to correct these defects by perceiving the therapist as someone completely fascinated and delighted by the patient. The patient has an insatiable need to tell about every detail of his life. In idealizing transference, the patient transforms the analyst into a person worthy of reverence and admiration, and then begins to feel his own importance and worth as a result of their relationship. In twin transference, the patient fantasizes that he and the analyst are in some way equal partners on a journey through life together. In this case, the patient no longer feels alone or empty. In all three transference models, the psychotherapeutic intervention is broadly similar: a deep empathic understanding on the part of the analyst. The transference and the relationships it generates are accepted and understood by the analyst, and as a result the patient can gradually internalize the analyst's personality. Thus the psychic organization which the patient could not carry out with his parents is now successfully structured and his health restored.

H. Kohut considered therapy as a process consisting, first of all, of such components as understanding and explanation. The first task of an analyst is to understand his customers as deeply and completely as possible. The tool of such understanding is empathy, and the necessary condition is the utmost openness. Empathy was recognized not only as a prerequisite for analytic work (which had been known since the time of Ferenczi), but also as the very essence of the method.

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Psychoanalysis is one of the most famous methods of treatment. At the same time, one of the most incomprehensible for customers. This type of therapy is based on the theories and works of Sigmund Freud, who created psychoanalysis.

What is psychoanalytic therapy?

Psychoanalytic therapy looks at the influence of the subconscious mind on thoughts and behavior. Attention is paid primarily to early childhood experiences: the therapist tries to analyze them in order to discover what role they played in the formation of the personality and in its present actions. People undergoing psychoanalytic therapy meet with a therapist at least once a week, and treatment may continue for several weeks, months, or years.

History of psychoanalytic therapy

Psychoanalytic theory grew out of the work of the famous psychoanalyst Sigmund Freud, who began to develop his therapeutic methods in the late 1800s. In 1885 Freud began working with Jean-Martin Charcot in Paris. Charcot used hypnosis to treat women suffering from what was commonly called hysteria. The symptoms of that illness included partial paralysis, hallucinations, and nervousness.
Freud continued his research into the possibilities of hypnosis as a treatment, but it was his work and friendship with Joseph Breuer that led to his most famous therapeutic technique. Breuer described the treatment of a young woman known to history as Anna O., whose symptoms of hysteria were resolved by talking about her traumatic experience. Freud and Breuer collaborated on a book called Essays on Hysteria, and then Freud continued to develop his methods of talking psychotherapy.

How does psychoanalytic therapy work?

Basically, the psychotherapist is engaged in listening to the stories of patients about their lives, which is why this method is often referred to as “talking treatment”. The therapist looks for events in the client's past that have played a significant role in his current difficulties. Psychoanalysts believe that an important role in the development mental illness and inappropriate behavior are played by the events of early childhood and the client's unconscious feelings, thoughts and motives.
However, other methods are also used in psychoanalytic therapy - free association, role-playing games and the interpretation of dreams.

What are the benefits of psychoanalytic therapy?

This type of therapy has many critics who claim that psychoanalytic therapy is too time consuming, costly and generally ineffective. But this type of treatment also has a number of advantages. The therapist acts as an empathetic and nonjudgmental listener in which the client can feel safe in identifying the feelings or actions that have led to stress or tension in his or her life. Often this simple exchange with another person can have a beneficial effect.

What are the disadvantages of psychoanalytic therapy?

The biggest disadvantage of psychoanalytic therapy is most often cited as its cost. Many clients are forced to undergo treatment for many years, so the financial and time costs associated with this treatment method can be very high.
Critics also argue that the effectiveness of psychoanalytic therapy can be called into question. One of the recent studies showed that between the results of treatment, clients of psychoanalysts and patients undergoing placebo therapy. Other critics - including Noam Chomsky and Karl Popper - suggest that psychoanalysis still lacks a scientific basis.

1960s By this time, it became clear that psychoanalysis as a method of therapy is not suitable for everyone who needs psychological help. Psychoanalysis takes a long time and requires large financial outlays; its purpose is not to cure a certain symptom, but to uncover the underlying causes of its occurrence. The development of psychoanalytic psychotherapy begins. Both of these psychotherapeutic practices are based on an analytical approach to the human psyche and its disorders. The difference between them is that in therapy the emphasis is not on the exploration of the psyche, but on the resolution of specific behavioral and psychological difficulties that the patient faces. Today, psychoanalytic psychotherapy is a common practice that allows patients to achieve tangible improvements in a relatively short time.

Definition

Psychoanalytic psychotherapy is often referred to as a lightweight version of psychoanalysis. The objectives of this type of therapy are as close as possible to the goal: to help the patient become aware of his unconscious conflicts - the causes of his behavioral and emotional difficulties. To achieve this goal, the psychotherapist listens to the patient (by the method of free association) and interprets unconscious contents. However, unlike psychoanalysis, psychoanalytic therapy places more emphasis on supporting the patient.

Operating principle

Psychotherapy, in its broadest sense, is a set of psychological actions aimed, firstly, at eliminating painful symptoms, and secondly, at the patient's personal growth. To achieve these goals, representatives of various therapeutic schools use different techniques and methods. Psychoanalytic therapy, like psychoanalysis, refers to the unconscious, believing that it plays a leading role in the formation of symptoms, disturbances in adaptation or in the patient's personal relationships. However, this direction has many differences from psychoanalysis. The patient does not lie on the couch, the session takes place "face to face" - the therapist thereby emphasizes a benevolent attitude towards the patient (in contrast to the neutrality of the psychoanalyst). Psychoanalytic psychotherapy, like psychoanalysis, is a “treatment with words”: the patient tells the therapist everything that comes to his mind, and thereby gives vent to his painful emotions, experiences and fantasies. Talking about past traumatic experiences has a therapeutic effect in itself. On the part of the therapist, it is reinforced by the interpretation (help in understanding) the patient's unconscious conflicts, as well as his non-critical, friendly attitude and support, which allows the patient to gain a new experience of communicating with another person.

Progress

The first 3-4 meetings are devoted, as a rule, to clarifying the complaints with which the person came to psychotherapy. The result of these meetings is the joint formulation of goals that the therapist and the patient can achieve as a result of work. After the conclusion of the therapeutic contract, the psychoanalytic psychotherapist, as it were, fades into the background, giving more space to the patient and encouraging him to express as fully as possible everything that comes to his mind. Gradually, the patient learns to freely express his thoughts and feelings, doubts, questions to himself, mentions his dreams and fantasies. The therapist, listening to the patient, focuses on his unconscious, trying to find in it the causes of his suffering or difficulties. Psychological transference also becomes an object of interpretation, as in psychoanalysis. This helps to see, right in the session, how the patient's past relationship is reproduced in his current relationship with the therapist.

Indications for use

Psychoanalytic psychotherapy is effective not only for neurosis, depression, phobias or personality disorders (like psychoanalysis). Her technique has also been adapted for the treatment of more severe disorders - psychoses and psychosomatic diseases (in these cases, the psychotherapist, as a rule, works in tandem with a psychiatrist or general practitioner). In addition, a new direction has been actively developing recently - psychoanalytic couples therapy.

How long? What is the price?

The duration of the course of psycho-analytic psychotherapy is shorter than that of psychoanalysis: from several months (short-term therapy) to 3-4 years. Meetings take place once or twice a week; their frequency depends on the psychological state of the person who applied for help, and on his material capabilities. The spread in prices depends on the experience and qualifications of the psychotherapist and ranges from 1,700 to 3,000 rubles per session (1 hour).

1. What is psychoanalytic therapy?
Psychoanalytic therapy is a psychotherapeutic mode of treatment intended (in the broadest sense) for the healing of intellectual and emotional distress. From everyday experience we all know how often a simple conversation helps us psychologically; moreover, it is a surprisingly simple technique that does not involve any special actions on the part of either the patient or the therapist. Psychoanalysis is both a method of self-understanding and a general methodology for studying human behavior, one of the branches of scientific psychology.

Psychoanalytic therapy is based on the idea that much of our behavior, thoughts and attitudes are controlled by the unconscious psyche, and not through ordinary conscious volitional control. By inviting the patient to speak, the psychoanalyst helps him to identify and manifest his unconscious needs, urges, desires and memories so that the patient can gain conscious control over his life.

This form of treatment for emotional problems was first developed by Sigmund Freud in the first half of this century. Subsequently, many psychoanalysts, building on the work of Freud, have expanded the range of problems that can be solved with the help of psychoanalysis. Along with new practical treatment techniques, new models of understanding human behavior have also emerged.

2. Who benefits from psychoanalytic therapy?

Psychoanalytic therapy is useful for anyone who wants to have a happier life and more personal and emotional flexibility. Adults, children, couples and entire families can participate in therapy. At the same time, they can attend both individual sessions of psychoanalysis and take part in group work.

3. What kinds of psychological problems can be solved in psychoanalytic therapy?

With the help of psychoanalysis, a very wide range of psychological problems (especially emotional ones) can be overcome. In details:
- emotional pain, depression, boredom, anxiety.
- inability to learn, love, work, or express emotions.
- irrational fears, anxiety without a specific known cause.
- feelings of own insignificance, emptiness, uncertainty of the future.
- lack of goals, meaning of life, ideals.
- feeling that you are too overwhelmed with responsibility, unable to relax and play.
- inability to set practical, achievable life goals for oneself, and accept responsibility for their achievement.
- unsatisfactory relationship with spouse, children, or parents.
- inability to establish and maintain friendships or love relationships
- the feeling of a "man-sand" who has absolutely no control over his life and believes that everyone is not the master of his own destiny.
- an overly regimented life dominated by rituals and obsessions.
- Compulsive overeating or inability to eat enough for good health.
- health problems that have a psychological origin.

4. What should a patient who seeks psychoanalytic help do?

5. How does a psychotherapist - psychoanalyst work?

The main function of the psychoanalyst is to carefully and attentively listen to the patient in order to understand him and facilitate his communication (lit.: facilitate). The psychoanalyst uses both his own intellect and feelings as a tool to obtain both verbal and non-verbal information on the patient's problems. The analyst must first recognize and understand the communication that occurs in the process of analysis and then transform what is noticed into information useful to the patient. To do this, the therapist asks questions, confronts distortions, and uses other techniques to help the patient desire, think, and experience comfortably.

6. What is the unconscious?

The unconscious consists of a large number of intellectual processes, desires, needs, attitudes, memories and beliefs that are not directly accessible to ordinary awareness. For many people it is often difficult to accept the idea of ​​the unconscious, it is difficult for them to accept that there is something that, apart from their volitional control, influences their lives. However, current research shows that many of our life choices such as spouse, friends, career, lifestyle, illness, etc. are based on motives that people usually do not clearly realize. A lot of bitter childhood memories stored in the unconscious nonetheless govern our daily behavior. With little understanding of their own unconscious urges, people become victims of emotional reactions that depress and destroy their lives. Psychoanalysis allows the patient to bring out these unconscious processes through behavior, language anomalies, dreams, and free association.

7. Why are dreams especially important in psychoanalysis?

Dreams play an important role in psychoanalytic therapy because (for those who remember them) they are, in Freud's words, "the royal road to the unconscious." In dreams, unconscious needs, memories, conflicts and desires of a person are expressed. Dreams can become a way of understanding hidden aspects of our Self, especially when explored with the help and invocation of the analyst's interpretations.

8. Why is the couch used in psychoanalysis?

A common joke, the couch is a misunderstood but very useful tool in improving the healing process. For most psychoanalytic patients, it provides an opportunity to relax, not be distracted by the presence of the therapist (who is located out of the patient's field of vision, at his head), and to comfortably express emerging thoughts and feelings. The use of the couch also emphasizes that therapy is not an ordinary social dialogue, but a specialized form of communication.

9. What is resistance?

During each psychoanalytic session, the patient exhibits behavior that interferes with the progress of the treatment. This kind of influence is called resistance. Because in psychoanalysis, all conditions are created so that the patient can achieve freedom of thought and action, the negative emotional forces in the unconscious that caused the patient's problem (specific symptoms) appear as obstacles to verbal therapy.

The patient may:
- feel unable to speak longer.
- to feel that he has nothing more to say.
- to want to keep something important secret from the psychoanalyst.
- to hide from the therapist some facts of which he is ashamed.
- to feel that what he says is not important, does not matter.
- constantly repeat in their stories.
- cunningly go about discussing some topics.
- want to do something else, and not participate in the conversation.
- want to get advice, not understanding.
- talk only about thoughts and ignore feelings.
- on the contrary, share only your feelings, without revealing their understanding.

These and many other forms of possible resistance make it difficult for the patient to discover himself, grow as a person, and generally become the person he wants to be. Together, the patient and analyst explore the meaning and purpose of the particular resistance and try to find the key to unlocking it so that the patient continues his personal growth. Modern therapists believe that the patient necessarily needs resistance and use a gentle approach to help him overcome resistance problems.

10. What is transfer?

Already the first psychoanalysts in their work discovered that patients can have a very distorted perception of the analyst. For example, an analyst with a quiet, polite demeanor may be perceived as an overwhelming tyrant. Or vice versa, the patient may be convinced that the analyst is in love with him, even if no manifestations of love were actually observed.

These kinds of feelings usually come from typical relationships with significant parental figures, who in the patient's past were parents, teachers, brothers or sisters. Sometimes the feelings towards the analyst represent actual feelings directed towards a real person from the patient's past, but transferred in the present to the closest and most appropriate parental figure - i.e. for analytics.

Not all patients experience the classic forms of transference, but it is useful for almost all patients in the course of analysis to study and understand the feelings that arise in them in relation to the analyst. This greatly helps in understanding the actual relationship, the severity of the need for personal growth, the expectations from others and the relationship to the patient.

11. Should psychoanalytic therapy focus only on early childhood events?

The events of the first five or six years of life have a decisive and lasting effect on the development of a person's character. However, the causes of emotional distress may not only be in traumatic events in early childhood, such as early loss of mother or dysfunctional family relationships, but/or in later life events. Past childhood events are only important if they interfere with the patient's ability to function effectively in the present. In this case, the therapist helps the patient to discover exactly how the childhood roots of emotional problems manifest themselves already in adulthood, and to overcome them.

12. Does psychoanalysis focus only on sex?

Most people have read or heard from various sources that Freud's main discovery was that it is sexual thoughts and feelings that have the most important place in life. However, modern psychoanalysts believe that anger, hostility, addiction, and a host of other urges can be just as important in shaping personality. Freud's patients were women of predominantly Victorian upbringing, and indeed most of their problems arose on sexual grounds, while modern patients more often have difficulties, such as coping with feelings of anger, loneliness, or lack of meaning in their own lives.

13. Is it possible for a patient to fall in love with a psychoanalyst?

Typically, patients experience a wide range of emotions towards the therapist. People who have received too little love or understanding in life may respond to the analyst's professional attitude (mindfulness, understanding, etc.) with a feeling of love. Equally common emotional reactions to the therapist are hatred, ridicule, indifference, or long periods of no feeling at all. The psychoanalyst never prescribes how the patient should feel. On the contrary, the goal of the analyst is to help the patient learn to understand and accept all the feelings that arise in him, no matter what they are.

14. Can psychoanalysis be done in groups?

Psychoanalytic therapy in groups is often very effective either in addition to individual sessions, or sometimes instead of them (the group is able to pluralistically interpret the images and experiences of the client - approx. M.R.).

15. How long does psychoanalysis last?

There are no restrictions on the duration of psychoanalysis. Some patients may benefit in a short period of time (six months or less), while others may continue treatment for several years. The average patient has been in therapy for about two years. Longer participation in psychoanalysis is neither a sign of excessive dependence nor an indication of the severity of the disease. It takes time to sustainably and reliably change the patient's relationship with other people and develop such traits of his character that will guarantee the absence of emotional stress in his life. A therapist of any school who promises healing in a specific and fairly short period of time is a scammer.

Therapy is considered complete when the patient's goals are achieved. When the patient is able to comfortably experience everything that he feels - both good and bad; when he is able to adequately include all these feelings in his relationship with the analyst (ie, be aware and analyze); when feelings do not interfere, but help in achieving his own interests and goals - therapy is completed.

17. How has psychoanalysis changed since Freud?

Psychoanalytic theory and therapy have also evolved since the time of Sigmund Freud. Freud paid the main attention in his research to the study of sexual desire, in particular the Oedipal phase of psychosexual development between the ages of four and six, when falling in love with a parent of the opposite sex arises. Since Freud, the main focus of psychoanalysis has been on how the individual enters the world precisely as a separate individual with self-awareness and a sense of positive self-respect. In modern models, psychoanalysis also deals with aggression, early mother-child relationships, social relationships, family dynamics, and psychosomatic problems.

Early psychoanalysis is suitable only for the treatment of the problems of neurotic patients whose roots are in early childhood. At the same time, contact between the patient and the analyst should be carried out as often as possible, preferably daily. The only interventions used by the analyst are interpretations or explanations of the patient's behavior. Today, patients rarely visit a psychoanalyst. Analysts have a wide variety of techniques that allow them to respond flexibly to patient behavior. Modern analysis is dynamically changing to meet the needs of people, both the expectations of the patient and the requirements of the practicing analyst.

18. Are there different schools of psychoanalysis?

Since the birth of Freudian analysis in the early 1900s, numerous approaches have been developed, including the theoretical and practical models of C. Jung, A. Adler, C. Horney, G. Sullivan, M. Klein, H. Kohut, and others. Each school of psychoanalysis focuses in detail on various aspects of the treatment or personality. The differences between these schools became less dramatic over time. Often, the differences between analysts trained within the same tradition can be the same or even greater than the differences between analysts from different schools.

19. What are the differences between psychoanalysis and other forms of therapy?

There are literally hundreds of types of psychotherapy available to all, and it would be helpful to understand something about each of them before choosing a therapist. Unfortunately, much of what has been written or said about psychoanalysis has been said by people with little experience or knowledge of modern modifications of psychoanalysis. However, there are still several main features that distinguish psychoanalysis from other forms of psychotherapy:
- the psychoanalyst prefers to treat patients without the use of drugs, although on occasion he may, in collaboration with a psychiatrist, prescribe drugs used to treat depression, psychosis, or hidden anxiety.
- the psychoanalyst does not give clear and specific recommendations (advice) on how the patient should manage his life or solve his problems. On the contrary, the analyst helps the patient to understand why he is unable to solve his life problems or what internal conflict deprives him of orientation on how to act in certain life circumstances.

When necessary, the analyst may delay solving problems until a later date, or may act decisively and quickly to keep the patient from harming or sabotaging treatment.

20. Isn't psychoanalysis just a fad or an outdated therapy technique?

Some social circles believe that psychoanalysis is outdated, and Gestalt or behavioral schools are the last word in treatment. The truth is that psychoanalysis is no more outdated, and no more a fad, than a visit to the dentist or surgeon. From the time when the practice of psychoanalysis relied on the early work of Sigmund Freud, the long history of psychoanalysis has brought new discoveries about the mind and methods of its treatment, which greatly enriches the therapist's ability to help patients.

21. Isn't psychoanalysis a kind of escape from reality?

For the most part, during psychoanalysis, the patient relaxes and calms down, but analysis can also be quite a tough job. It often seems to relatives or friends that psychoanalysis is an artificial support, a kind of "psychological crutch", that it leads to an escape from reality, to an illusory escape from problems. In fact, in the course of analysis, the patient acquires a real opportunity, calmly and realistically to face life events. In the course of analysis, he is not encouraged to be dependent; on the contrary, he must become independent and responsible for his own destiny.

22. Can a person change himself, only at the expense of his willpower?

A person with a strong will can of course influence the external manifestations of emotional problems (symptoms), but as a rule, he very often does not realize and does not notice most of them. Of course, many people have radically changed the form and content of their own lives even without psychoanalysis, but the solution of emotional problems caused by unconscious conflicts can only be adequate with the help of psychoanalysis.

23. Is it possible to use introspection?

Rather not, because most people have such a high degree of resistance that the results of introspection are either too superficial or confirm existing ideas about themselves, rather than bring about radical changes. Of course, some people have fairly developed abilities for introspection, but without a regimen of regularly scheduled sessions, without working through information with the help of an experienced analyst, the information they learn about themselves is of little use in life. In addition, much of who we are is determined by our relationships with other people. The analyst provides an opportunity to observe our typical behavior in close enough relationships (between analyst and patient) and safely model new ways in relationships with others.

24. How do you train to be a psychoanalyst?

Psychoanalysts are perhaps the most rigorously trained of all therapists. In order to engage in analysis, the psychoanalyst must undergo a deep personal analysis, complete a comprehensive theoretical training, and for some time to personalize patients under the supervision of senior analysts (supervision). This training is usually not available at graduate schools or universities and usually psychoanalysts are trained in independent specialized institutes (training institutes).

The teachers of these institutes are usually experienced analysts, and the programs are tested and accredited by serious psychological organizations such as ABAP or APA (American Psychological Association).

In general, training in psychoanalysis requires previous basic education as a psychiatrist, psychologist, social worker, medical practitioner or lawyer, nurse, although this is not strictly required for training in psychoanalysis. At the end of their studies, analysts may also have M.D. (doctor of medicine), Ph.D. (PhD), M.S.W., or M.S.N. Psychoanalytic training usually lasts from five to ten years, because the trainee, after theoretical training, must undergo analysis himself, then he must engage in therapy under the supervision of supervisors, until the supervisor recognizes his right and competence to engage in analysis on his own. Unlike training in various psychological schools, which lasts one or two semesters, analyst training continues until supervisors, teachers, and the trainee agree that it is completely completed.

25. How much does psychoanalytic treatment usually cost?

Fees are usually agreed between the patient and therapist on a one-to-one basis, but are usually quite comparable to prices for other forms of psychotherapy. Sometimes psychoanalysis fees may be partially reimbursed by some medical insurance funds. Patients unable to pay the standard fees to private analysts may seek help from public psychoanalytic clinics or find other sources of funding.

26. How often do psychoanalytic sessions take place?

Freud and other classical psychoanalysts tried to meet with their patients at least four to six times a week. Modern therapists meet with patients less regularly, according to the needs of the client.

27. How to choose the right psychoanalyst?

A psychoanalyst must be a certified specialist who has a document on completed psychoanalytic training in an accredited educational institution. It is desirable that he has experience in solving problems of the type experienced by the prospective patient. Once you have chosen a therapist, you should go through 4-6 analysis sessions as a trial period to see if you and the therapist can work together.

28. Does a psychoanalyst have to be a man (or a woman)?

For most people, the gender of the analyst is not important. An exception is made for patients who have lost their parents in early childhood, who are often advised to seek a therapist of the same gender as the lost parent; on the contrary, people who experience strong antipathy towards either gender are advised to avoid working with a therapist of the corresponding gender. There are many theories about the specific relationship between patients and analysts of different sexes, but these theories are usually criticized after some time. The conclusion is very simple - the patient must choose a therapist in whom he feels trust.

The problem of evaluating the effectiveness of psychoanalysis as a therapeutic system has traditionally not been the focus of research, while the genre of describing individual cases, on the contrary, is primordially traditional. Moreover, it was the practice of discussing isolated individual cases that to a large extent contributed to the birth of new theoretical concepts (as happened with the concepts of "transfer-countertransference", for example) or led to modifications of psychotherapeutic methods and systems. This state of affairs is not accidental for psychoanalysis, with its close attention to phenomenology and qualitative analysis, although it is precisely this position that psychoanalysis owes to obstructivism on the part of positivist-minded representatives of scientism (see, for example, almost 50 years of criticism of psychoanalysis by G. Yu. Eysenck).

In this regard, Freud's statement is interesting, referring to the beginning of the formation of psychoanalysis as a new method of psychotherapy, in which he, in fact, anticipated the subsequent position of the opponents of the method of scientific thinking discovered by him. In Essays on the History of Hysteria, he admits with some surprise: “... It seems to me strange that the case histories that I write read like novels and that they cannot be evaluated from the point of view of strict scientific character. I am only consoled by the fact that the nature of the object of research rather than my own inclination led me to this. Modern psychoanalysis brings this method of scientific analysis closer to hermeneutics and understanding psychology (according to X. Tome and X. Kahele), as well as to a kind of psychoanalytic archeology that recreates the history of entire eras from their “debris”. “The ability to reconstruct the experience of another,” the authors write, “is one of the prerequisites from which one must proceed if psychoanalytic treatment is carried out.” It is worth noting that even taking into account the obvious limitations of case study as a method of cognition of universal patterns claimed by the classical scientific paradigm, modern psychiatry and clinical psychology have accumulated such a brilliant archive of the study of individual cases by K. Jaspers and R. Lang, E. Fromm and D V. Winnicott (a number of great names can be continued) that the legitimacy of such a method of cognition "by precedent" is hardly worth arguing. At the same time, in the last two decades, another scientific paradigm has also been established, connected, on the one hand, with the Ulm direction, headed by Tome and Kahele, who actively support the study of the psychoanalytic process and its variables, who have collected a whole scientific library from verbatim records (transcripts) of psychoanalytic cases. , and on the other hand, with the direction of North American psychoanalysts led by L. Luborsky, M. Horowitz, L. Benjamin, who are developing a cognitive-psychodynamic research model and special methodological tools for text analysis based on a more scientistic research paradigm. It is not necessary to exclude scientific discussion and constant revision of the theory of psychoanalysis, its explanatory constructions, fundamental concepts (metapsychology) from the entire space of research. Hot discussions are accompanied by pragmatic questions about indications and contraindications for psychoanalysis, about the possibility of integrating psychoanalysis with other psychotherapeutic procedures and, accordingly, changing the traditional forms of the psychoanalytic setting. Of course, one of the key issues remains the evaluation of the effectiveness of psychoanalysis, however, the issue is intractable in relation to all existing psychotherapeutic systems due to the insufficient development of the methodology itself. scientific research in the field of psychotherapy, its interdisciplinary position in science and the discrepancy to a large extent of the humanitarian conceptual apparatus with the natural science principles of empirical research.

The total amount of empirical research using specially designed procedures for assessing the variables of the therapeutic process, including the nature of psychopathology, the stages of therapy as a process, the role of transference and countertransference, is still small.

In their review of modern psychotherapeutic systems, J. Prohaska and J. Norcross (1994) give a panorama empirical study the effectiveness of psychoanalysis, referring to works done primarily in a positivist manner. Based on the publication of these authors, we describe some of them. R. Knight (1941) compared the expected prognosis for patients who are on examination for at least six months with an assessment of its results. The data included analysts' tentative hypotheses that the patient would "apparently be cured"; his condition will “significantly improve”, “stay unchanged”, or “deteriorate” by the end of the analysis. This study was conducted as a cross-cultural study, including data from patients seen in psychoanalytic institutes in Berlin, London, Chicago, and Topeka. Dividing patients according to clinical diagnosis, Knight obtained the following results (Table 2.1). On average, about half of the patients who complete psychoanalysis are cured or have improved significantly.

Table 2.1

An early study of the effectiveness of psychoanalysis depending on the patient's diagnosis (R. Knight, 1941)

R. Knight's research included only subjective data (judgments of therapists about the results of treating their own patients), but it was the starting point for more controlled experiments. The following are short descriptions representative data from comparative studies.

The first comparative study was presented in 1953 by R. Heine, who compared the effectiveness of psychoanalytic psychotherapy with Adlerian and Rogerian. Eight patients in each of the three forms of therapy rated themselves on the basis of 60 favorable and 60 unfavorable changes. Although there was no statistical analysis of self-reported data, Heine concluded that patients experienced improvement with all forms of therapy. In his conclusion, the changes in patients who have undergone one of the forms of therapy are no more favorable than in other forms of therapy.

In 1965, P. May and A. Tuma compared the effectiveness of the treatment of patients with schizophrenia by the following methods: only psychoanalytic therapy; psychoanalytic plus medication, electroshock; normal hospital care without special treatment. Patients with schizophrenia underwent a preliminary examination by a group of psychoanalysts and were qualified as patients with a moderate prognosis, whose treatment could lead to significant changes. Each group consisted of 20 patients who first applied to the hospital. The psychotherapy lasted one year, was carried out by psychiatrists under the supervision of psychoanalysts. As criteria for the effectiveness of therapy, the following indicators were analyzed: recurrence of hospitalization during the first two years after discharge, total number days in the hospital for three years after the first visit, post-treatment status on the Menninger Health-Sickness Rating Scale, studied by eight psychoanalysts on the basis of additional interviews with patients and assessment of the behavior of patients by staff. No significant differences were found between the psychoanalytic therapy and custodial care groups.

W. Rice (1967) tested the hypothesis that psychoanalytic psychotherapy contributes to the growth of professional efficiency and productivity. Therapists who observed 414 full-time patients received information from them regarding their weekly income before and after treatment. For comparison, income information was obtained from 145 patients awaiting treatment by educational and professional level correlated with the experimental groups. The mean income in the experimental groups was $80 before treatment and $112 after treatment. On average, the duration of treatment consisted of 57 therapeutic sessions. There was no difference between initial income in the experimental and control groups, but after treatment, the average income of patients in the treatment group was $22 higher than the average income in the control groups. Department of Labor statistics show a $6 per week pay increase for patients undergoing professional education Unfortunately, no statistical analysis and comparison with placebo and other treatment groups was performed.

In 1973, O. Kernberg presented a paper on the Menninger Foundation's Psychotherapy Research Project. This project began in 1959 and continued for 20 years. The study included 42 adult patients (both outpatient and inpatient) undergoing psychoanalysis or psychoanalytic psychotherapy. Psychoanalysis lasted an average of 835 hours;

psychotherapy - 289 hours. Most of the patients improved (as measured by the HSRS-Menninger Mental Health Scale), and there was no difference between those who had undergone psychoanalysis and psychoanalytic psychotherapy. Direct comparisons between the two treatments, however, are difficult to make because patients received one treatment or the other not spontaneously, but by differences between the two groups of patients. Another limitation, in order to draw conclusions about the effectiveness of the two types of therapies, was the lack of placebo comparisons for both groups with and without treatment.

In his book 42 Destinies in Treatment, project leader R. Wallerstein refers to the material accumulated over more than 30 years of treatment, as well as observations of the subsequent life changes of 42 patients who participated in the research program. In parallel with the report of O. Kernberg (1973), Wallerstein draws the following conclusions:

• the traditional distinction between "structural change" and "behavioral change" is being questioned;
• resolution of intrapsychic conflict is not always necessary condition changes;
• supportive psychoanalytic psychotherapy leads to greater than predicted success;
• classical psychoanalysis leads to less than expected success.

Treatment outcomes tend to converge rather than diverge. Regardless of the type of therapy, a high level of ego strength and especially the quality of interpersonal relationships show a significant correlation with positive changes.

D. Malan summarized the results of a series of studies done by him and colleagues at the Tavistock Clinic in London to find out whether short-term treatment using the same interpretations as in the full analysis is effective for patients of varying severity of the disorder. Data were collected five to six years after the end of treatment in order to assess the persistence of the effects of short-term therapy. The factors most correlated with the delayed effects of psychotherapy in both studies were the following: use of interpretive technique, focus on transference relationships, and strength of motivation to change. Positive outcomes correlated with successful dynamic interaction, defined as the therapist's interaction with the type of patient who seeks insight and accepts the therapist's interpretation, especially interpretations relating early childhood relationships to current behavioral patterns. As in the Menninger Project, these studies did not compare results with placebo and untreated groups, which limits the conclusions.

In one brilliantly conceived study, R. Sloan, F. Staples, A. Kristol, N. Yorkstone, and K. Whipple (1975) compared the effectiveness of short-term psychoanalytic psychotherapy with short-term behavioral therapy. 30 patients were selected in each group, 34 waiting for treatment made up the control group. The patients were treated at the university outpatient clinic, two-thirds of the patients were diagnosed with neurosis, the rest with personality disorders. Each patient was initially assessed by one of three experienced psychiatric experts not associated with the study. The patient, together with the evaluator, singled out three main symptoms on a five-point scale. The treatment lasted 4 months, with an average of 14 sessions. Behavioral therapists were free to choose the techniques they believed would be most helpful. The chief expert used only counterconditioning techniques, the second most competent therapist emphasized cognitive restructuring, and the third expert had no preferences. Psychoanalytic therapists have traced the role of the therapeutic relationship, the patient's capacity for self-exploration, expression of feelings, and insight. Therapeutic methods employed included free association analysis, dream analysis, and defense interpretation.

The most striking findings of the study were that both treatment groups showed significant improvement compared to the no-treatment group, and neither form of treatment was most effective. By symptom rating, 80% of patients in each treatment group improved or were cured (versus 49% in the control group). In terms of overall self-regulation, 93% in the behavioral group achieved improvement compared to 77% in the psychoanalytic psychotherapy group (among those waiting for treatment - 47%).

After four months of therapy, all patients were free to choose whether to continue or start therapy, so follow-up data are difficult to assess. One year after the start of therapy, it was found that the initial data remained the same in all groups. After two years, there was no difference in improvement rates between groups, but by that time, those awaiting treatment were receiving the same amount of therapy as the experimental treatment group.

Several significant differences were found between the types of patients who achieved improvement on each type of therapy. The most striking difference was that patients with the highest MMPI scores for hysteria and psychopathy worsened with psychoanalytic psychotherapy, while those with high hysteria scores improved with behavioral therapy. There has been a trend towards the usefulness of behavioral therapy for a wide range of patients.

In the 1980s X. Strupp and his colleagues published the results of a series of studies on the Vanderbilt-1 Project, which contrasted the experience of treating a group of neurotic patients by college professors (non-therapists by profession), specially selected as understanding and cordial, with a comparative group of patients whose treatment was carried out by experienced, psychodynamically oriented psychotherapists. This study was not just a test of the effectiveness of psychodynamic psychotherapy; there was a search for how to separate the effects of non-specific (general) factors, represented by the warmth and understanding of college professors, and specific factors, represented by specific techniques used by occupational therapists. All patients were males aged 17 to 24 years, with peaks on the MMPI scale 2, 7, 0 (depression - psychasthenia - social introversion). In both treatment groups, the results were higher than in the control groups without treatment. However, the initial group analysis of the data obtained did not show higher results in the group where the treatment was carried out by occupational therapists; subsequent analysis found only as a trend for professionals to be more efficient in working with healthy patients. In neither group were therapists more effective in treating patients with more severe characterological problems. Obviously, support and cordiality are non-specific therapeutic factors, whether assistance is provided by occupational therapists or special techniques. In addition, the positive effects of psychotherapy will be more pronounced with a less severe depth of disorder.

In 1979 and again in 1984, J. Prohaska published reviews of psychoanalytic research that concluded that efficacy had not been adequately tested. It is safe to say that psychoanalysis gives better results than in the absence of treatment at all. But it cannot be concluded that psychoanalysis has also proven to be effective in comparison to credible placebo therapy. In fact, according to these reviews, no study has found that psychoanalysis or psychoanalytic psychotherapy is more effective than other forms of psychotherapy.

The problem of the effectiveness of psychoanalysis and psychodynamic psychotherapies has been the focus of recent research using the method of meta-analysis, a statistical technique that quantitatively combines the results of many studies. Meta-analysis was used by M. Smith, J. Glass and T. Miller (1980), as well as M. Smith and J. Glass (1977) to study the effectiveness of psychotherapy based on the results of 475 studies. Approximately 29 studies were on psychodynamic treatments and 28 studies were on psychodynamic eclectic treatments. When evaluating comparative effectiveness with other forms of psychotherapy, psychodynamic forms of therapy were rated as more effective and only marginally less effective depending on the interpretation of the data. In an attempt to repeat the study of M. Smith and J. Glass in an improved version, D. A. Shapiro and D. Shapiro (1982) excluded those studies that had at least two treatment and one control group. Most of these 143 studies used behavioral forms of therapy. The authors concluded that their more rigorous study yielded largely the same results as the earlier meta-analysis by M. Smith and J. Glass. Other studies have demonstrated some differences in the effectiveness of the applied forms of treatment. Thus, there was a slight superiority of behavioral and cognitive methods and, accordingly, a relatively lower efficiency of dynamic forms of therapy. The difference in indicators was insignificant; to a greater extent, the outcome of treatment could be correlated only with the type of problems to be treated than with the type of treatment itself. In a review of 19 studies, M. Swartberg and T. Stiles (1991) confirmed that short-term psychodynamic psychotherapy outperforms cases of no treatment, but is inferior to alternative forms of psychotherapy both immediately after treatment and after a year.

There is a discussion about the significance of these differences, found by the method of meta-analysis of the studies. Differences in the assessment of the comparative effectiveness of therapeutic systems may be attributed to the influence of many factors, including the theoretical orientation of the researchers, the validity of the variables used to measure, the individual characteristics of the personality of the patients studied, and the type of disorder.

Since most of the comparative studies were conducted by cognitive and behavioral therapists, they may have consciously and unconsciously used variables favorable in terms of their preferred therapy in their study design. The relatively small statistical advantage in such studies does not mean that cognitive and behavioral models have an undeniable advantage over other forms of therapy.