Real conditions sometimes impose the attemp to perform psychoanalytic treatments at two sessions a week, but such treatments should be carefully considered. Unconscious fantasies on the common therapeutic project, co-created by the analyst and patient in the analytic field, have a continuous organizing effect on the development of the therapeutic process. It seems that psychoanalysts and psychotherapists, having a different training and professional identity, develop with their patients unconsciously different therapeutic projects.
In this paper I will consider a type of “partial” psychoanalytic treatment, characterized by twice a week frequency, which tries to be as similar as possible to psychoanalysis in its procedure and, hopefully, also in its results. Some consider and call such treatments psychoanalytic psychotherapy. I would prefer to call such treatments “more or less partial psychoanalysis” (this term was used by G. Hautmann, 1979; Merton Gill in 1984 proposed “psychoanalytic therapy”, while Widlocher in 1999 called similar treatments, a bit ironically, “light” analysis).
Some statistics show that in many countries most analysts don’t have more than 1 or 2 patients in analysis (with 3 or more sessions a week). Therefore, it is evident that during most part of their working time they treat patients with a lower frequency. Nevertheless, discussions about this are rather rare.
Two times a week treatments are a large part of the psychotherapic activity of psychoanalytically oriented psychotherapists too. One problem on which I would like to focus here is, if – or how much – some of these treatments may be considered psychoanalysis. More in general, we could discuss, what is actually going on in such treatments. I think that it is indispensable to raise questions about it, not only because it concerns a large part of our work, but also because this helps us think about some parameters of the psychoanalytic technique, to better outline their meaning. Without such a reflection they risk to remain in the shadow of the “obvious”, “taken for granted” and therefore not thought. Still we risk slipping into tautologies like “this is analytic because analysts do so” (though I will later assert something similar, but I hope not in a dogmatic way and with some valid motivations).
I will proceed considering:
1. The kind of treatment I have in mind in this paper.
2. A schematic outline of some differences between psychoanalysis and psychoanalytic psychotherapy.
3. How the reduction of frequency to twice a week may influence the analytic process.
4. The question of session frequency in general.
5. What is the difference, when a low frequency treatment is run by an analyst rather than by a psychotherapist.
The main idea in this paper is that the therapeutic process is deeply influenced by the therapist’s basic mental attitude and this is influenced and structured by the professional identity and training too. This may also help us to better understand the psychoanalytic identity and the role of the analytic training.
- “More or Less Partial” Psychoanalysis
I have in mind some patients who present a clear indication for a psychoanalytic treatment, but they cannot accept a 4 times a week frequency because of real external obstacles.
They live in a city far from mine, where no analyst is available and they cannot travel to my office, due to their work and their family duties, more than twice a week, or they absolutely cannot afford to pay more than two sessions a week. Neither have they any clear enough “focal” conflict area, on which a short-term therapy may be “focused”. It seems that their only other choice is to scrape by with some drug support or to turn to a psychotherapist for a psychoanalytically oriented psychotherapy. In these cases, with such external limits, I think that it is ethically correct, if I try to do what is possible and what I consider could be more useful for these patients, though it is not technically the optimal and most effective choice. If the psychic structure of the patient seems adapted, I begin a treatment on the couch, which formally differs from a psychoanalysis only due to the twice a week rhythm. As we will see later, the differences are actually wider and deeper.
Some such treatments may be rather similar to a true analysis (or in same lucky cases be actually such), other less. I think that most depends on the patient’s capacity to bear separations, because if this is insufficient, it will be very difficult for the patient to try to develop an enough solid sense of continuity between sessions.
Honestly, we must consider that generally it is financially more rewarding to work at a low frequency, as usually patients consider how much they may pay a month. So often psychotherapists, who have once a week treatments may ask for higher fees and earn more than analysts. Therefore there could be a temptation for analysts to lower the frequency of their treatments also for unmentionable financial reasons.
2. Differences between Psychoanalysis and Psychoanalytic Psychotherapy
This is, of course, a rather complicated subject. A lot of books, papers and meetings have dealt with it. The matter is complicated also by the deep differences existing among how the analytic process is conceived within different analytical theoretical approaches. I will not enter into such a complicated and sometimes conflicting discussion.
It is very difficult to delimit and define what psychoanalytically oriented psychotherapies are. Rather diffused and common are psychotherapies, in which a poorly trained psychotherapist, or a beginner (like most of us were, when we started to work with patients), just talks with patients using some psychoanalytic concepts with almost no structured technique. In some cases, non-analytical tools, like suggestion and counselling are systematically used in what are usually called supportive psychotherapies. Such psychotherapies, though still inspired by some psychoanalytical concepts, are very distant from the real “psychoanalytical” ones.
Still, there are some modifications of the classic analytical technique, which have been introduced to make possible and more effective treatments of psychotics or of other severe patients. Other modifications are introduced to reach a quicker result with a short-term focused therapy.
These approaches will not be discussed here, but I will consider just those psychoanalytically oriented psychotherapies, which are very close to the analytic technique and which are not supportive. I try to outline some of their basic features and the differences in comparison to psychoanalysis.
ο there are fewer sessions a week and the patient is usually face-to-face;
ο the treatment has some limits in time and space (I mean the inner space-world);
ο the attention of the therapeutic couple is more focused on the present external and on the past internalized relationships, than on the patient-therapist relation, therefore transference interpretations are not central, regression of the patient is not fostered and so the development of a transference neurosis is not aimed at;
ο the therapist feels that he is watching to what is happening to the patient, more from an “outside”, less involved, position;
ο usually deeper layers of the psyche, the most primitive internalized object relations, are not worked through, namely not within the transference, while less regressive and more recent contents are dealt with.
The difference in psychoanalysis is that:
ο there are more sessions a week and the patient is on the couch;
ο there is a long term and open-ended treatment, with no time limits and with no previously determined direction (Freud’s “evenly suspended attention”, 1923, p. 238; Bion’s, “analyst without memory and desire”, 1967; Ogden’s “analyst’s and patient’s reverie”, 1997);
ο the attention of the therapeutic couple is mostly focused on the patient-analyst relationship and the transference distortions of this relationship are interpreted, and then connected to the patient’s past and present external relationships. Therefore the transference interpretations are central and, to better understand what’s happening on in the analytic relationship, the use of the countertransference is essential;
ο patient’s regression is fostered and so a transference neurosis is aimed at;
ο the analyst is rather deeply involved in the patient’s transference neurosis, in the externalization of the patient’s inner object relations and the analyst’s countertransference reactions are strongly and continuously stimulated;
ο the analyst is in a more difficult situation than a psychotherapist, as he has to understand and to interpret the relationship, in which he is at the same time intensely involved – he works from “inside”;
ο deeper layers of the psyche, the most primitive interiorised object relations, are activated in the transference and worked through.
To a certain extent, we could compare the two approaches imagining a theatre. In psychotherapy the patient with his inner objects is on the stage, while the therapist is sitting in the audience watching what is going on, while in analysis both, patient and analyst, are on the stage, though the patient is the main actor.
- 2. Some of the Changes in the Analytic Process at a Low Frequency
A twice a week frequency, actually, implies more changes in the analytic process, than it would appear.
The reliability of the analyst is determined by many factors. One of these is also the quantity of his concrete presence in the patient’s life. If it is reduced, it might not always be compensated by the quality of his presence. (It reminds the situation of mothers, who are obliged to leave their infants for whole days in a kindergarten, and, in order to avoid feelings of guilt, they try to convince themselves that a good quality of presence in the evening may fully compensate their absence during the day).
It is far more difficult to reach the sense of continuity among sessions (which is difficult to reach in almost every psychoanalysis for a long time). It requires a successful elaboration of the interruptions-separations at the end of the session and of the week. Envious reactions, stimulated by these interruptions, toward the analyst who “has so much and gives so little” have to be interpreted and overcome too. But in a low frequency a cancelled session means a whole weeklong break. Therefore, these patients are hesitating for a much longer time, before they dare to abandon their rigid defences and regress. Some of them don’t succeed at all in this difficult task. A longer time between sessions means that the patient brings into sessions more contents of his external life and this is easier used as a defence against inner contents.
The analyst is less relaxed and could be less disposed to a state of free-floating attention or of reverie. He could also be more concerned about the kind of interpretation to give, especially at the end of the sessions, knowing that the patient will not be there again next day.
The development of the transference neurosis is more difficult. Some factors, which implement it, like the systematic interpretation of the transference and the frequent deep empathetic interpretations, are less effective when patient and analyst meet more rarely. All the emotions are paler. It could be like the difference between watching a movie on television at home, with all the advertisement interruptions and the usual home noises, or being in the darkness of a cinema, where the screen covers almost the whole visual field and the absence of any other visual or auditive stimulus, allows us to be intensely absorbed and involved by the emotions of the story we are watching.
Sometimes it could be traumatic for the patient to bear anxieties or excitements for longer periods between sessions. During a period of intense regression a patient of mine described the end of the session with these words: “It is like to pull out a nipple from the baby’s mouth just when he begins to suck, or like drawing out a penis from the vagina just before the orgasm!” Another patient was speaking of “being thrown out of a warm and bright home into a dark and cold street”. Surely, it is not the same if the patient comes back next day or after 3-4 days. (Nevertheless, we should consider that, when such contents are felt, thought and expressed, and not just acted, a lot of the analytic work has already been done.) Such difficulties to regress are typical for relatively more structured patients. Borderline patients or psychotics may regress massively also within a twice a week rhythm, but I am not considering such patients in this paper.
4. The Question of Session Frequency
Different psychoanalytical theoretical approaches imply also different frequencies of psychoanalytic treatments, which go from three to five times a week. What I would like to stress is that, from my point of view, the frequency is a very important factor and a higher frequency is usually connected with a more intense development of the analytic process. Therefore, in analysis we should try to set up a high frequency whenever possible, in order to give to the patient the best chances to undergo a successful treatment. But, the frequency is far from being the only and the absolute criterion to establish if a treatment is analytic or not. Everybody knows that there may be treatments four or five times a week, in which almost no analytic process develops, because the analytic couple is not adapted to making it possible, while rather good processes may sometimes develop in twice a week treatments. This shows us just that the number of sessions a week in itself is not the indispensable and sufficient element to perform an analysis. But it doesn’t mean at all that, to develop an analytic process, frequency is not a relevant factor.
We have no reason to reduce the frequency, offering in that way to our patients a worse chance, except if unavoidable obstacles really do exist. It is quite common to hear our patients say, like one of mine said: “Now that we have passed from three to four sessions, I must admit that four sessions are for me the minimum in order to be relaxed. Before, I was always tensed, worrying about the first and the last sessions of the week. On Mondays I was blocked by the past week-end interruption, while on Fridays I was blocked by the next interruption”.
Nevertheless, there are also some patients who are so afraid of an intensive treatment that they would never accept four sessions from the very beginning. Therefore, especially with young patients and with people that have no idea of what psychoanalysis is, I prefer to begin twice a week, adding the third and the fourth session, when they are more acquainted with what an analytic treatment is. In this way I can better avoid, that some patients stop short after the beginning and also that patients accept four times on the couch as a totally incomprehensible mysterious rite proposed to them by “an omnipotent magician”.
Last but not least, if we don’t idealize our profession and ourselves, we should admit that patients should also have the possibility to know how we work and, to a certain extent, what kind of people we are, before they could trust in us and let themselves regress in our hands. If we leave apart our auto-idealizing mask, we must admit that we are not so ideal and sometimes some patients may do the right thing, if they run away from their analyst, not trusting him.
For us too, psychoanalysts or psychotherapists, sometimes it could be useful to have a longer period of time to better know our patients, before we resolutely turn towards deeper, more regressive layers of their inner world, towards an analytic treatment. Still, it has to be also considered, that it is much easier to increase the number of sessions a week than to decrease them, without damaging the ongoing analytic process.
I remind also that the inner setting (built within the analyst’s attitude) should be distinguished from the external one. The mental representation of the setting shouldn’t be too concrete. Anyhow the external setting must not be under-evaluated, because it is extremely difficult to maintain the inner setting, when it is not appropriately supported by a correct, real, external one.
5. Differences between an Analyst and a Psychotherapist
In my practice, as I have said before, sometimes I have to decide what to do with a patient, who needs an analysis, but he has no possibility to undergo a treatment more frequently than twice a week. I have described one possibility, which is that I begin with him a “more or less partial analysis”, with such a reduced frequency, and we both try to do our best. But for some of such patients neither this possibility does exist, as my schedule is full and so are those of the few colleagues psychoanalysts working in my city. In this case I address the patient to a psychoanalytical psychotherapist. Sometimes I can see later how things are going, if the therapist comes to me for some consultations or supervision. In such situations I have noticed quite an interesting phenomenon. Patients, whom I would treat psychoanalytically for many years, with a psychotherapist they often finish their treatment in two, three years and sometimes with not bad results. Or at least both, therapist and patient, agree that some work has been done, that the patient feels better, though they are both aware that some problems have not been settled. In comparison with these cases, for which I must confess that sometimes I feel a bit envious to my colleague psychotherapists, my similar cases go on quite longer, often over ten years. With these patients I am sailing for years in stormy seas or in desperately sticky swamps, before we arrive to a sunny and flowering landscape. Compared to psychotherapists I seem affected by a sort of “filobatism”, as I need to pay great attention to the patient’s most regressive layers, to his most primitive object relations. Or better said, I could allow myself to be freely led to such areas by the patient’s free associations.
In the meantime, contrary to myself-analyst, psychotherapists don’t feel at all the lack of a third and a fourth session. My impression is that, when confronted with deeper contents, which they are not used to deal with and which they know only theoretically, they unconsciously try to avoid them, they don’t see and interpret them. Unwittingly they give to their patients messages like: “Let’s not get too deep into these issues!”, “I feel uneasy, when you dwell on such contents or such emotions.”, “It is useless to go in this direction.” Such unconscious messages arise in the patient the feeling that the therapist is not fully able to accompany him and to guarantee him the indispensable safety, if he regresses too much, if he expresses his primitive anxieties. The patient could perceive, in addition to his natural fear, also therapist’s hesitation to sail toward deeper seas, on which the therapist has never sailed before either. At that point a collusion between the patient and the therapist could be established and continues up to the end of the therapy, with the unconscious aim of sailing only in a more limited calmer bay.
On the contrary, with an analyst, the patient will perceive, consciously and unconsciously, that the person who is treating him is rather familiar with regressive areas, because he has already explored similar ones and has safely come back from them with his patients, for whom this trip has been at the end also rather productive. I believe that the patient is very much influenced by his perception of the therapist’s (or analyst’s) feelings in regard to the paths that may be walked down by the analytic couple.
Constructivists and intersubjectivists emphasize how each of the two members of the analytic couple influences and, to a certain extend, structures the other (Bonfiglio, 1994). We may think that this concerns also the therapeutic plan, in its conscious and unconscious aspects. To be more exact, in the analytic field the analyst and the patient are continuously creating and developing common unconscious fantasies, (this is close to Ogden’s “analytic third”, 1994.) Among these fantasies a common image of their analytic work is also always present and influences the development of their therapeutic relationship. Greenberg and Mitchell (1983), referring to Winnicott, write that: “The organization of the child’s experience is preceded by the organizing perception that the mother has of him and depends on it.” We may extend this also to the couple therapist-patient or analyst-patient. A couple’s unconscious fantasy shapes the analytic field and has a continuous organizing effect on the development of the therapeutic process.
Psychoanalysts, or psychotherapists, don’t bring into the relationship only some individual aspects, but also professional ones, their experience, knowledge and even the image they have of their therapeutic action. All this interacts with patient’s hopes, fears, motivations and resistances. All this contributes to structure also a common therapeutic plan. A large part of this is preconscious or unconscious and influences the direction and also the limits of the therapy.
During the therapy the patient is deepening his knowledge of the analyst and is unconsciously learning far more about him (his way of reacting, blind areas, emotional reactions, feelings etc.) than we usually admit. I believe that the analyst’s psychic structure naturally limits (or enlarges) every analytic process. We should add to this limiting (or enlarging) factor also analyst’s knowledge, experience and theoretical or technical approach. All these factors interact with the patient’s structure and his problems. The analytic process and its development will be deeply influenced by this. I suppose that all this is influencing the patient treated by a psychotherapist into accepting a relatively short-term treatment, while with an analyst the patient will become more open to a long-term treatment.
My analytic treatments last differently, if they are 2, 3 or 4 times a week. They tend to be longer the less frequent are the sessions. But, if I account the total number of sessions of a treatment, the difference is less evident.
During the first long phase of almost each analysis there is an obstinate sense of timelessness. But I think that at the same time there exists a deep sense of time, in an almost biological dimension, which is connected to the life cycles and to the same length of human life. Little by little this becomes connected to the developing conscious sense of time and at a certain point it appears explicitly. This is one of the factors that contribute to put an end to treatments that become too prolonged and/or have exhausted their therapeutic potentiality.
Beyond resistances, which of course may play their role too, the patient’s decision to end the treatment, may be influenced also by the unconscious feeling that in this specific situation with this therapist, or with this analyst, no further growth is possible, that the therapeutic process is exhausted and that continuing they will merely go in circles. With a psychotherapist it often happens earlier than with an analyst, because the later is better equipped for sailing in wider seas.
Let us see a bit more in detail what the analyst’s equipment is. In comparison with a psychotherapist, the analyst usually has undergone a deeper and more exhaustive personal analysis. The analyst was accompanied by his supervisors for an important part of his first two “travels” through deep unknown areas. During his further activity, as analyst with analytic patients, he has “explored” more and more of such areas.
But there is still another basic factor. As musicians, to develop and maintain their level, they must play in excellent orchestras, so analysts must participate in their professional group activities (society scientific life, congresses, conferences), not only to constantly improve their “instrument”, but also to avoid its deterioration. Collaborating with colleagues analysts they continuously learn about difficulties, which others meet in such “travels” and about less known areas of the human mind. It is difficult to trust an analyst, who would work isolated from other analysts, not benefitting of an enriching working group atmosphere. Also intense countertransference feelings may be far easier mentalized, understand and managed with a group of colleagues, than working in isolation. Still, nowadays no single mind can contain and elaborate the enormous quantity of data that are continuously produced in psychoanalysis, so as in any other science. It is clear that, the better our training is and the more qualified the analytic groupis, to which we belong, the better and deeper we will be able to work with our patients.
I hope that I could have contributed to a bit better understanding of what is happening in a psychoanalytic treatment, what are some differences with psychotherapy and what could be the difference between a working analyst and a working psychotherapist.
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Fonda, P. (2016). About the Setting with Two Sessions a Week. Rom. J. Psychoanal., 9(1):35-49