How we structure things

First, let's define our terms. When I talk about psychoanalysis I'm referring to a treatment that consists of 4 or 5 sessions weekly and that unfolds over the course of several years. When I talk about psychoanalytic psychotherapy I'm referring to a treatment that consists of 2 or 3 sessions weekly. I'm reluctant to work with patient's less than twice weekly, but am willing to so long as we agree to consider those meetings a protracted consultation process, meaning a decision will eventually be made either to formalize the treatment or to decide not to work together. (Keep in mind that although the process is long, the acute problems that bring patients to treatment tend to resolve relatively quickly. What keeps patients coming back is their own awareness of the need for deeper work, and their desire to really make some changes to themselves. It's pretty clear to people pretty early on in the process that this is a different sort of therapy than they've had in the past, and that brings hope and fortifies resolve.)

The years are organized into regular and predictable breaks. I take two weeks in the winter and three weeks in the summer and some scattered federal holidays. I make every effort to schedule any other times I'm away from my office months in advance. In this way, the process resembles a graduate program or a work schedule. All of this is for a reason. The sort of change that psychoanalysis aims toward must be worked at/for and this requires commitment. Psychoanalysis is not unique in this regard; rehabilitations and physical therapies of various sorts are structured in much the same way. Significant change happens slowly and only through a process of accretion.

Sessions are the patient's responsibility. While I do currently take insurances that pay for multiple weekly sessions, there is the inevitability of missed sessions to account for. One way we give the process structure and stability is by making those absences that the patient is responsible for the patient's financial responsibility. Of course this means that when you're absent I don't fill your spots. This policy is sometimes difficult for patients to understand, but it becomes more clear as my commitment to you and your time is more fully grasped. To enter this sort of treatment is to ask me to get to know you well so that I can show you the aspects of yourself that are hard for you to see on your own. Regardless, this is standard practice in psychoanalytic communities and I always make an effort to be responsive to an individual's logistical needs. Some negotiation is always possible, but the bottom line is that the process requires a certain regularity and consistency and policies to support that.

Mind as system, world as representation

Part of what makes psychoanalysis so difficult to describe is that it's based on the idea that the mind is a complex system. Complex systems consist of parts that interact with one another to produce something greater than its parts alone. This is hard for most people to conceptualize because it implies a view of 'a person' as an emergent property of semi-independent but interacting parts, and this flies in the face of more religious or spiritual views of the person as a soul or more neo-liberal views of the person as the product of pure self-creation. Some people feel that to think of 'a person' in these terms is to mistreat them by discounting their personhood. The trouble with that position is that it binds would-be helpers to only that which the patient themselves believes to be true or is capable of knowing about themselves. To go beyond what the patient 'knows' is seen as a sort of arrogance or psychic imperialism on the part of the helper. From the perspective of psychoanalysis, none of us can know ourselves fully because 'we' are creations of mind the vast majority of which remains inaccessible to introspection. We require outside information about ourselves to be psychologically healthy.

Another part of what makes psychoanalysis so difficult to describe is that while it is a theory of how the mind is composed and operates, so too is it a theory of how the mind builds up an understanding of the external world. In other words, psychoanalysts, at least in the traditions I'm most aligned with, are realists. We believe there really is a reality out there that exists independnetly from anyone's perception or interpretation of it. This means that there is such thing as truth. It may be hard to get to, and we may never be fully without doubt as to whether we have fully understood a particular phenomenon in the world, but there is something out there to be known. From a psychoanalytic perspective, because our minds are a product of evolution they are designed to detect certain truths, but so too do we have the ability to ignore or deny those truths in various ways and this is what leads to dysfunction. Our thinking gets twisted up, the efficiency of our minds suffers, and the image of the world our mind's are capable of building becomes distorted or impoverished in various ways as a result. This is what symptoms are. Importantly, this is not a theoretical notion but an empirically verifiable fact and it's these facts that are encountered in psychoanalytic treatment.

This notion of truth is anathema to many in contemporary culture who feel committed to the belief that all truth is relative. In the world of talk therapy, a belief like that leads to treatments in which the therapist can do little more than validate the thoughts and feelings of their patient. From a psychoanalytic perspective, on the other hand, there simply are realities that demand recognition. That doesn't mean that it's the analyst's job to insist that those realities be recognized as such, in fact this is explicitly NOT what psychoanalysis is about. But recognizing that such realities exist does put analysts in a position to be able to show patients what happens, i.e. what the consequences are relative to their inner world, for denying truths that the patient themselves gives clear evidence for have recognized in the first place.

First description

Psychoanalytic treatment is the slow work of watching how the mind transforms information from both inside and outside, creating particular experiences of self and other in the process. There are no ready made answers or directions about how to live or act. There is only the psychoanalytic method which we do our best follow during each session and that, when practiced consistently over time, allows for something real and effective and meaningful to happen. It's a bit hard to describe this from the outside, but it's not magical nor mystical nor necessarily mysterious.

It's something like: What happens in your life begins to happen in the treatment. Your mind works the same whether you're in a therapy session or not. That's the point. Yes, in a way, you're interested in learning how to be different somehow. The trouble with that is, "but how?" The paradox of this way of working is that different comes from getting more clear on what already is. If you think about it, how could it be otherwise? I can't tell you how to be. Anything I could say to you would land only intellectually and would be nothing more than you could read on the internet or in a book. No, the work is in diving into each individual moment and getting hold of how your mind moves and shapes experience 'behind the scenes' so to speak. To practice this is to come to realize how difficult it is to be honest with oneself. The treatment just acts as a viewing instrument of sorts; it concentrates the otherwise diffuse patterns of your life, the ones you live through but only tend to recognize in retrospect, or the things you know about yourself but try not to for various reasons.

In other words, the analyst does not preach, condone, teach, encourage, coach, judge, criticize, or persuade. We do our best simply to describe particular sorts of processes occurring during the session. These processes are ways that information from the session is given specific interpretations and leads to particular sorts of mind states and experiences. This means that what the analyst says is empirically verifiable to the patient themselves. Not only should it sound true, but once seen the truth itself should be self-evident. When these truths are struggled with as such, the mind is freed of the work of avoidance and so begins to function better. The resulting clarity gives the therapeutic process meaning, structure, and directionality, and helps the patient to tolerate the pain and difficulty that are also part of it.

In still other words, you're asked in each session to speak as freely as possible about whatever feels important to you. The direction is to do the best you can to allow your mind to work and to say your thoughts outloud as they occur. The experience at first is awkward and difficult, but soon one begins to understand that to speak freely in this way (and free is always relative and meaningfully constrained) is to say things that feel true and alive and meaningful to us and we register that as vulnerable somehow. To share thoughts in this way is to put the analyst in a position to see something real about us, and this risks painful feelings. Conviction about and trust in the process is generated from an experience of the analyst as relatively neutral, which makes it obvious that the painful feeling is not being inflicted from without but freed from within, and recognizing this initiates growth promoting processes related to mourning, repairing, and forgiving.

Second description

Each of us lives within a model of the world that the mind creates for us moment by moment. We look out from within it onto a 'world' it is representing. Our perceptions and experiences are structured by this model, and the limit of our ability to sustainably change ourselves is set by it. In other words, while we do perceive and interact with a world that does indeed exist outside of ourselves, we never have direct access to it. We reach it only through the representation we make of it, that our minds make of it for 'us'. But in bridging the gap between outside and an inside it is also charged with organizing, the mind leaves an uneven seam. Bits that really belong to 'us' get mixed into the representation we make of the outside world. These facts are both widely accepted and ubiquitously under appreciated.

Psychoanalysis, as a theory and a practice, is built on this understanding of things. It itself is a model which aims to make the mind’s component processes observable as such and in real time. These processes amount to the activity of meaning making. They are what the mind does when it organizes raw stimuli, i.e., when it constructs its representations. They are bits of "us", and "we" exist always in relationship with the surrounding world. The bits gotten hold of in analytic sessions are those uneven points in the seam (the points where our model of the world has, without our realizing it, ceased to faithfully reflect the world itself). Identifying this allows for a mechanism of action (a way of helping) based on something other than education (as in cognitive therapy), "exposure" (as in behavioral therapy), or reconstruction (i.e., as in "dynamic" therapy). To get hold of these processes is to be able to see how one's models of self, other, and world have come to distort more than reveal the realities they intend to represent. As a result, one comes to understand how, in an important sense, they have been creating their own version of the world as opposed to struggling with the one given to them.

Importantly, the power of psychoanalysis does not hinge on the external definition of Truth. The analyst does not act as an arbiter of Truth, but as an observer in the position to watch the mind construct it's version of reality from a perspective inaccessible to the patient themself (we are all bounded in this way). In a way that's difficult to describe but straightforward to show, what gets talked about in psychoanalytic sessions is how this process of construction happens and why. Speaking to these processes as they occur has a powerfully sobering effect. These are moments when we know ourselves more completely and therefore see the world around us more clearly. It's the state of mind restored in these moments that implies the abatement of symptoms and increased ability to productively engage the world and people around us. These are moments when one learns that how the world looks and feels to us has a lot to do with how the line between self and other gets drawn, and when the opportunity to understand why the line gets drawn like that in the first place opens up. Helping the mind to draw the line between self and other more accurately greatly improves its efficiency. Our ability to think gets a lot better. Importantly, this does not eliminate suffering but makes it more meaningful and hence productive.