First description

What's distinct about psychoanalytic practice can be brought out relative to a simplified version of CBT. In CBT 'irrational thoughts' and 'pathogenic beliefs' are seen as primary, irreducible mental contents which cause unwanted emotional states like anxiety and depression. The treatment consists of challenging these mental contents directly in an attempt to eradicate or change them.

Psychoanalysts argue (and some research suggests) that trying to get someone to change their thinking in this way doesn't actually work the way people think it does. Those thoughts and beliefs don't go away. What happens is that the therapist's message is identified with to a greater or lesser degree. The patient's capacity to avoid or ignore or challenge the problematic thoughts may increase, but the basic split in the personality doesn't heal. The potential remains for the old, problematic thoughts and beliefs to be activated again. Energy still needs to be expended to keep them at bay. Interestingly, an important aspect of CBT treatments is the strengthening of systems of avoidance. That's what coping skills are. In this way of working, the meaning of the problematic thoughts/beliefs is left untouched.

By contrast, psychoanalytic theory is a comprehensive model of the mind. The mind is a meaning making machine; it functions like any other machine/organ/system, and can be studied just like any other part of nature. What we've learned over time, is that the mind is composed of parts and components that interact with one another, with the body, and with the outside world to produce consciousness and subjective experience. When things are working well, subjective experience is created in a steady stream overtime that's characterized by the qualities of creativity, evolution, and growth (i.e., personalities grow). When the mind breaks down, some aspect of experience stops evolving. Instead of growth and change through time, aspects of the personality get stuck and patterns of experience and behavior get repeated again and again. This is felt as suffering; it's what symptoms are. In the former state, the mind is more efficiently able to synthesize information into meanings and appropriately direct behavior. In the latter state, there is a break down in some aspect of meaning synthesis - a mind glitch if you will. Psychoanalytic treatment tracks these meaning making processes so as to identify the mental processes that underlie symptom formation. In practice this amounts to finding the reasons that 'Irrational thoughts' and 'pathogenic beliefs' exist in the first place and for what reason they are being maintained. Coming to know these reasons eliminates the glitch which resolves symptoms. In other words, the psychoanalytic treatment model is healing through self-knowledge.

Second 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. This is called the psychoanalytic method and, when practiced consistently over time, it allows for something real and effective and meaningful to happen. It's a bit hard to describe this, 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. 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. If I were to tell you and you were to implement it, that wouldn't be therapeutic change but something more fragile and superficial. No, therapeutic change comes from getting hold of how your mind moves and shapes experience 'behind the scenes' so to speak. The treatment just acts as a magnifying glass or a canvas; it concentrates the patterns you create in your life, putting the analyst in a position to see and reflect them back to you. The treatment is a confrontation with yourself.

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. These mind states and experiences are lived ideas and constitute the patterns, or pieces of the patterns, that you're coming to treatment for help with. When these lived ideas, these unconscious processes, these bits of meaning 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 on that day in that moment. The direction is to do the best you can to allow your mind to work and to say your thoughts out loud 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. This neutrality makes it obvious that what the analyst says is merely a reflection of something occurring in the moment that, without realizing it, you had been excluding from your conscious awareness. Recognizing this and grappling with those observations initiates growth promoting processes and leads to therapeutic change.

Third 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.

Fourth description

Think about it like this: to come into treatment is to enter into an agreement with me, and this agreement has several aspects.

There are fees to be set and session frequency to discuss but let's skip over those for a moment to missed appointments. This is a long form process that spans years of time. Missed appointments are inevitable and require attention for two main reasons. On the one hand there is my livelihood to consider - your fees become, very directly, my salary. I work intensely with patients which means my practice is small, and (for clinical as well as practical reasons) I don't treat session times as interchangeable. But more important to you there is the effectiveness of the treatment to consider. A missed session policy that holds you financially responsible for your hours whether you attend them or not (regardless of advanced notice given) is an essential aspect of the treatment.

To be helpful to you I need to be able 'to think' and unless you guarantee your session fees, I am unable to think as well and as neutrally as the treatment requires. In other words, to be effective I must be insulated - to a reasonable degree - from the vicissitudes of your life and decision making processes. Though I am very engaged with you, at the same time there is a way I stand back. Without this space I would be unable to comment neutrally on what happens in your mind and between you and I in the treatment. By guaranteeing your session fees, you're enabling me to stand back and direct my attention to the broader patterns that are the main focus of the treatment. This is how paying for your treatment makes it yours.

The treatment is a long process with a beginning, a middle, and an end. It just takes a long time to develop the understandings and insights and for those insights to be wrestled with and eventually integrated. Of course there will be sessions or weeks that you are unable or choose not to attend (e.g., for a vacation or business trip), but even when you're away you are still 'in treatment', and when you return your hours are there for you waiting. This is a reality that will make itself felt one way or another, and psychoanalysis is about facing and staying in contact with reality.