Reasons Why Psychoanalysis and Psychodynamic Psychotherapy Are Becoming Rare

American psychoanalysts are an endangered species. For many years, Freudian theory has been providing a comprehensive framework to describe human behavior. Nowadays, however, the traditional psychoanalysis and psychodynamic psychotherapies are in dramatic decline. As per Freud, internal or psychological forces motivate behavior, and abnormality occurs when there is an imbalance in the internal forces (neuroses). To illustrate, for a patient with anxiety, the anxiety symptoms reflect his unresolved unconscious conflicts (repression), which were either onset in early childhood (e.g. the Oedipus complex) or later on by trauma. Freud made interpretations for the distressed and made their afflictions somewhat more comprehensible to the rest of the society by developing the treatment method, psychoanalysis. As of recent years, the aim of therapy are becoming less about the undoing of repression and work more towards patient’s greater integration and coherence. For example, evidence-based psychotherapies and efficacy studies for Cognitive Behavioral Therapy (CBT) are being favored and such short-term, behaviorally focused treatments are at ample demand. Psychoanalysis and psychodynamic approaches are, as a result, endangered; they are becoming unappealing in the contemporary psychotherapy ‘marketplace’. Reasons may include dilemmas with treatment’s duration (long-term) and costs (not covered by health insurance companies), the invention of quicker treatments to mental illnesses such as CBT and psychotropic drugs and other sought-after self-help guides, yoga and meditation. Furthermore, there may be arising issues with Freud’s use of a biased sample, his over focus on sexual issues, and determinism. Moreover, psychoanalytical therapies lack scientific validity and depend on the therapist’s subjective interpretation.

There are hundreds of journals and case studies written by psychoanalysts, therefore, psychodynamic approach has explanatory power, but even so, it lacks scientific evidence. The psychodynamic model provides explanations for the causes of abnormality, such as childhood traumas, but it lacks the empirical research evidence needed to support the theory. Psychoanalysis is competing with CBT because CBT has been ‘proven’ to be a satisfactory psychotherapy with its efficacy studies. Efficacy studies are more challenging to carry out on psychodynamic psychotherapies because of their long-term characteristic. Long-term efficacy studies are nearly impossible to do. The main issue is the control variables for the research: how could a 5-10 year therapy have the same structure amongst patients.

Psychoanalysis heavily depends on the therapist’s interpretation of what the patient says. Would a dream about swimming in the ocean really reflect on the patient’s infantile fantasies of sleeping with his mother? According to Freud, if the patient accepted his analyst’s interpretation then it was probably correct. However, if the patient strongly disagreed with and rejected the analyst’s interpretation, it must be the patient’s conscious mind rejecting an unacceptable but accurate interpretation. Either way, the therapist’s interpretation, or Freud’s subjective analysis, presides.

Freud based his ideas mainly on his subjective analysis of middle class Viennese women. He used a biased sample of a group of predominantly middle-class Viennese women between 20 and 44 years of age, whom were all dealing with serious emotional problems. No men, no children, no upper-class, lower-class patients. This sample could not reliably generalize to the general population. Additionally, when developing his theory of psychosexual development, Freud only studied one child (Little Hans). A theory from a study with a sample size of 1 most definitely cannot generalize the entire population.

The psychodynamic theory tends to focus a great deal on sexual issues, mainly infantile sexual fantasies and repressed sexual wishes. There is a de-emphasis on the importance of interpersonal and social factors in causing and maintaining mental disorders. It may be that the failing of resolving the Oedipus complex isn’t the cause of the abnormality, but perhaps a present-day dysfunctional parenting style leading to an insecure attachment.

Psychoanalysis and psychodynamic therapy is very determinist in proclaiming that childhood traumas will lead to abnormal behavior in adulthood, however, they ignore any other possible influences of genetics (biology), reward (behaviorism), and thinking patterns (cognitive approach). Which, evidently, are feasibly more emphasized and explored in other treatments. In CBT, the focus is not on the past, the unconscious and the undoing of repression, but the work on greater integration and coherence within the society. The early years of life, while still seen as the foundations to character development, are now understood in terms of attachment, rather than primarily oedipally.

In psychoanalysis, childhood experiences and traumas are the main focus and the aim of the sessions is to hypothetically reconstruct the patient’s past. In contrast to that, CBT focuses on the ‘here-and-now’. Nowadays, insight alone is no longer seen as sufficient in overcoming neurosis. The ‘present transference’, or the feelings, thoughts and emotions evoked by the present (here-and-now) of the analytic situation have become the main objective.

The practice for the classical Freudian treatment of three to five weekly sessions, each 45 to 50 minutes and costing up to $500, takes patience and affordability. Health insurance companies and psychotherapies Federal regulators are moving the American health care system toward the evidence-based treatments. Since modern health services seem to always be in a hurry (time is money), they are choosing to apply their means predominantly towards the short-term, behaviorally-focused treatments, which can be manualized and evaluated quickly. For psychoanalysis and psychodynamic psychotherapy this means that costs will not be covered. The question becomes: what percentage of the patient’s needing treatment can afford the 100-200 hours of psychotherapy that are needed to make a significant impact on their disorder.

Being a long-term therapy, psychoanalysis may encourage patient’s dependency on his analyst. The patient may become safe around the therapist, but when not at therapy (in safe place), in social situations or at home the patient may feel unsafe and anxious and forget all the progress made in therapy (regression). This is a vivid disadvantage of psychoanalysis in comparison with CBT, where the brief therapy discourages the patient’s dependency on the therapist and encourages the patient’s self-sufficiency.

Before the invention of psychotropic drugs, if the patient wasn’t cured, their foremost option was to keep going back to therapy for more analysis. With science and research bettering everyday, pharmacological treatments for disorders are showing effectiveness of psychological interventions. The rise of biological alternatives in the form of psychotropic drugs (for example Prozac) can now treat depression and anxiety quickly.

Self-help book and videos, yoga, and meditation are also drawing people away from psychoanalysis and psychodynamic psychotherapies, as they are cost efficient and a here-and-now relief/solution to depression and anxiety. The online web and Google allows people to fabricate self-diagnoses and self-therapy/self-help practices.

Overall, psychoanalysts are an endangered species, but there are purists still insisting on the classical Freudian way. On the other hand, many analysts tend to revitalize their treatment by approaching integrative psychotherapies: analysts may use breathing exercises and other techniques. Perhaps integrative and eclectic psychotherapies may be the solution to keeping some of the classical psychoanalysis alive and in practice, but only future analysts and patients can influence that.