The Analytic Attitude: The Essence of What We Mean by ‘Psychoanalysis’
by Ralph Roughton
Psychoanalysis is a process of self-discovery as it unfolds within an intense therapeutic relationship. The analytic attitude is the principle that differentiates psychoanalysis and psychoanalytic psychotherapy from other types of therapy that aim primarily for symptom relief and behavioral change.
Psychoanalysis has evolved from the days when the focus was on sexual and aggressive drives and on conflicts between impulses and defenses within the mind of the patient. Analysts now focus more on relating to the whole person rather than analyzing conflicts between id, ego, and superego. Instead of instincts, we think about attachments and relationships.
Transference is now seen through the lens of a two-person relationship rather than merely as a projection of past desires and fears; countertransference is regarded as not only inevitable but useful in the analytic process. The analyst is both a real person in a human encounter and a relatively neutral partner in an exploratory process of discovery.
Psychoanalysis and psychoanalytic psychotherapy are similar in their underlying theories, they share basic techniques for exploration and understanding, and they aim for change that is deeper than symptom reduction. They differ from each other primarily in the intensity and depth of the exploratory process and in the breadth of understanding and change. Psychoanalytic psychotherapy is more focused and limited in scope, while psychoanalysis is an open-ended exploration of all aspects of a person’s life.
There is a much sharper divide between these analytic modes and other forms of talk therapy, such as cognitive, behavioral, and supportive therapies. For convenience I refer to the latter group as CBS and to the psychoanalytic therapies as PSA. In CBS approaches, the emphasis is on actively working to change symptoms and behaviors, whereas in the PSA therapies the emphasis is on understanding and freeing the patient’s inner life.
In the CBS group, therapists are more active in offering suggestions, clarifications, and supportive comments. Cognitive and behavioral approaches are used to teach better techniques for dealing with daily life and with troubling thoughts and emotions. The intent is to reduce symptoms and improve functioning without deep exploration.
The relationship with the therapist may be an important part of these therapies but is not usually the focus of attention, nor is it explored for its roots in past relationships. Transference usually functions as a supportive bond that is addressed only if it becomes a negative force interfering with treatment.
In contrast, the PSA approach regards symptoms and problems in daily living as manifestations of the patient’s inner life, reflecting enduring patterns that developed to cope with earlier relationships or traumatic experiences. These patterns persist and determine the way the person feels about himself, the way he tries to gets his needs met, and the way he responds in interactions with other people. Current life situations trigger these old patterns and result in feelings and actions based as much in the past as in the present.
In the analytic approach, the treatment focus goes beyond current life events to uncover and understand these unconscious patterns, especially as they are revealed in the developing relationship with the analyst. Thus the relationship itself becomes a fertile field for exploration and analytic work. Analysts do not discount the patient’s present reality, but an analytic approach explores current reality in the context of enduring patterns. This requires the luxury of frequent and unhurried sessions, usually three to five times a week for psychoanalysis and one to two times a week for psychoanalytic psychotherapy. Insight into past unconscious conflicts, as well as the experience of recreating and then resolving those conflicts within the analytic relationship, are what make the psychoanalytic approach effective and enduring.
Nevertheless, an analytic approach is not necessarily the preferred treatment for everyone. For some, one of the CBS approaches may be preferable to the long and arduous journey of psychoanalysis, either because of the nature of the problems or the goals for treatment, or because resources are limited.
Nor do I want to imply that CBS therapists never work in this exploratory way. But the PSA approach is characterized by the consistent focus on discovering and understanding the patient’s inner life and on a thorough understanding of the analytic relationship as it develops and is then resolved. Whether this is at the greater intensity and depth of psychoanalysis or the more focused and limited psychoanalytic psychotherapy, I call it “working analytically.”
Merton Gill advised that we simply begin to work in an analytic way and do as much analysis as the patient’s circumstances allow. So how do we do that? The analytic process requires a particular attitude, in a unique relationship, occurring in a unusual setting.
First, the treatment process must be guided by an analytic attitude of non-intrusive curiosity and non-judgmental acceptance, a desire to discover the truth about a person’s emotional life in depth, respect for the patient’s individuality and autonomy, the ability to tolerate ambiguity, the patience to wait for the unfolding of discovery, and the humility to revise one’s conjectures when wrong. Being helpful is a long-range goal, not a quick fix.
Second, the analyst must be free enough from her own conflicts to allow the patient to project his needs, desires, idealizations, and hate onto her and to work non-defensively with these expectations. For extended periods, she may need to be simply a container for the patient’s painful affects, confusion, and hopelessness without succumbing to those feelings herself. She must be receptive to the patient’s transference needs and not rush to correct the distortions. Being an analyst requires emotional engagement in an intense human relationship, while also maintaining appropriate boundaries, refraining from exploiting the patient’s vulnerabilities, and keeping one’s own subjectivities and biases in check so as not to distort the patient’s process of self-discovery.
Third, the analytic approach requires an atmosphere of safety, trust, and confidentiality that will allow the patient’s inner life to unfold. A completely private setting, with consistency and regularity, is important with regard to appointment times, frequency, and fees. The analytic setting becomes the background of stability against which the patient’s inner script will play out.
The analytic attitude, the intense and profound relationship between the two partners, and the consistency of the setting all foster the unfolding of an inner life beyond what the patient is consciously aware of, in order to discover what he has spent a lifetime avoiding — and, in the end, to make life better.
Ralph Roughton, MD, is a founding member of the Atlanta Psychoanalytic Society and past director of the Emory University Psychoanalytic Institute. This blog entry is adapted from his book chapter, “Listening as a Psychoanalyst,” which appears in Charles Silverstein, ed., The Initial Psychotherapy Interview: A Gay Man Seeks Treatment (Elsevier Insights, 2011).