Psychoanalysis

A brief overview: Going to the root

While traditional forms of psychotherapy are often helpful in addressing specific life concerns and problems, they may fall short in helping individuals shift more fundamental and enduring patterns in their relationships with others, their relationship with or sense of themselves, and their experiences of past, present, and future.

Psychoanalysis is interested in understanding life patterns at their root by uncovering their history and what may lie beneath them. It begins with the idea that some of the forces shaping our life patterns remain outside immediate conscious awareness. Through in-depth guided reflection, exploration of patterns in the safety of a therapeutic environment and relationship, and examination of their costs as well as possible alternatives, psychoanalysis guides individuals towards more wholistic forms of health.

Going to the root of challenging patterns also means becoming more familiar with how underlying patterns can put obstacles in individuals’ growth or development. Psychoanalysis offers an opportunity to understand these obstacles and rekindle individuals’ natural impulses to grow and change. As the less visible aspects of experience become more available for reflection, new ways of feeling, relating, and acting can become possible.

What is contemporary psychoanalysis?

Psychoanalysis has changed substantially since the time of Sigmund Freud. Contemporary psychoanalysis is interested in helping individuals understand the workings of their minds as well as in shining light on the often hidden intricacies of the relationships between internal, interpersonal, cultural, and sociopolitical dynamics that shape their daily experiences in the present and past.

Psychoanalysis helps individuals make sense of the often bewildering complexities of conscious and unconscious thoughts, intentions, impulses, recurring patterns, contradictions, emotional reactions, expectations of other people, fantasies, dreams, avoidance, and aspects of experience that may be difficult to put into words.

The relationship between patient and analyst is also important. Patterns that occur elsewhere in life can become visible within the analytic relationship itself. Exploring them together can provide an immediate way of understanding how a person experiences closeness, difference, dependency, disappointment, conflict, recognition, and change.

What happens in a psychoanalytic session?

Psychoanalysis usually involves meeting several times each week. This frequency creates continuity and allows emotional and relational patterns to be explored as they unfold.

• Individuals in a psychoanalytic session are invited to speak as freely as possible about whatever comes to mind, including thoughts that seem irrelevant, contradictory, embarrassing, trivial, or difficult to explain.
• There is no predetermined agenda and no requirement to arrive with a particular topic.
• The analyst listens closely to the content of what is said, as well as to patterns, shifts in feeling, recurring themes, things that seem difficult to approach, and what may be developing between the two people in the room.
• The analyst guides the patient’s reflections, may ask questions, make observations, offer interpretations, or help draw attention to connections that have not previously been apparent.
• Psychoanalysis is a collaborative process with a distinctive form of conversation, focused on sustained exploration rather than advice, exercises, or predetermined skills.
• Most individuals lie on a couch, which intends to facilitate introspection and reflection about thoughts, feelings, fantasies, and associations.
• Sessions can be held in-person or remotely

How is psychoanalysis different from psychodynamic psychotherapy?

Psychoanalysis and psychodynamic psychotherapy share the same underlying interest in understanding the whole person rather than treating symptoms in isolation. Both can involve substantial depth, unconscious processes, attention to relationships, and meaningful long-term change. The distinction is therefore not that psychotherapy is “surface-level” while psychoanalysis is “deep.” Psychoanalysis instead creates a particularly intensive setting in which psychological patterns can be encountered, understood, and worked through with greater frequency and continuity.

	Psychoanalysis	Psychodynamic Psychotherapy
Frequency and intensity	Usually 3–5 sessions per week. The greater frequency creates substantial continuity and allows emotional and relational patterns to be explored as they develop.	Usually once or twice weekly. The lower frequency can allow greater emphasis on current circumstances and changes occurring in everyday life.
Focus and aims	Broad, open-ended exploration of personality, relationships, emotional life, symptoms, unconscious processes, and longstanding patterns in how a person experiences themselves and others.	Exploration of emotional and relational difficulties, often with a more defined focus on concerns such as depression, anxiety, relationships, grief, trauma, or life transitions.
Methods and therapeutic relationship	The patient is encouraged to speak as freely as possible about thoughts, feelings, memories, dreams, fantasies, and reactions. Free association and the analytic relationship are central, allowing recurring patterns, unconscious conflicts, and expectations to be explored within the treatment itself.	The patient is also encouraged to reflect openly on emotions, relationships, and experiences. Unconscious patterns and the therapeutic relationship are explored, often with somewhat greater conversational flexibility and attention to life outside therapy.
Duration and commitment	Usually long-term, often extending over several years. It requires substantial time, regularity, emotional engagement, and financial commitment. The couch is commonly used, although practice varies.	May be brief, intermediate, or long-term, depending on the person’s difficulties and goals. It usually involves a smaller weekly time and financial commitment and is generally conducted face-to-face.
Change and working through	Change may emerge gradually through repeated exploration and working through. Insights are revisited across different contexts, helping transform longstanding ways of experiencing oneself, others, and the world.	Insight and change also develop over time, often with greater emphasis on recognizing and changing patterns in everyday life and addressing the concerns that brought the person to treatment.

The appropriate treatment for each individual depends on the nature of the difficulties, what individuals hope to accomplish, their interest in this kind of exploration, and the practical commitment that treatment requires. These questions can be considered together during an initial consultation.

When might psychoanalysis be worth considering?

Psychoanalysis may be particularly worth considering when:

• Difficulties and patterns are longstanding or persistent
• When the same relational or emotional patterns keep returning despite efforts to change them
• When previous therapy has been helpful but something important still feels unresolved
• When understanding yourself more deeply has become an important goal in its own right

It requires a significant commitment of time, regular attendance, emotional effort, and financial resources. It is important to consider whether the intensity of treatment fits your circumstances and goals. For some problems, another psychotherapy, medication, medical treatment, or a combination of approaches may be more appropriate. An initial assessment helps determine the most suitable treatment.

Evidence for psychoanalysis

There is a meaningful body of research examining psychoanalysis itself, including treatments involving several sessions per week over a number of years.

• A meta-analysis of 14 studies of psychoanalysis found large improvements in psychological symptoms as well as in broader aspects of personality functioning. Importantly, these improvements were generally maintained, and in some studies continued to increase, after analysis had ended (de Maat et al., 2013).
• Large long-term follow-up studies have reported similar findings. For example, research in Germany found that 70–80% of former patients showed substantial and lasting psychological improvements an average of more than six years after completing psychoanalytic treatment (Leuzinger-Bohleber et al., 2003).
• Studies in Finland following patients for as long as ten years have likewise found enduring improvements in symptoms, personality functioning, relationships, and social functioning following psychoanalysis (Knekt et al., 2011; Lindfors et al., 2019).
• Some of the most interesting research suggests that the benefits of psychoanalysis may emerge gradually. In the Munich Psychotherapy Study, patients receiving psychoanalysis averaged 234 sessions over approximately three years. At a three-year follow-up, they showed greater improvement in depression, general psychological symptoms, personality functioning, and social relationships than patients who had received less intensive psychodynamic psychotherapy (Huber et al., 2013).
• Other long-term studies have found that symptom improvement may occur more quickly with shorter treatments, while psychoanalytic treatment may show additional benefits over time, particularly in areas such as personality functioning and the capacity to understand and manage oneself in relationships (Knekt et al., 2011; Lindfors et al., 2019).
• More recent research comparing intensive psychoanalytic treatment with cognitive behavioural therapy for chronic depression found substantial and lasting symptom improvement with both approaches, with no clear advantage for psychoanalysis in reducing depressive symptoms, but greater changes following psychoanalytic treatment on measures intended to assess deeper changes in personality functioning (Beutel et al., 2023).

These findings are encouraging, but they should not be overstated. Because psychoanalysis is lengthy, individualized, and difficult to study using conventional clinical-trial methods, there are relatively few large randomized trials of high-frequency psychoanalysis. The evidence therefore supports psychoanalysis as a serious and empirically studied treatment, while the research base remains smaller and less definitive than that available for many shorter psychotherapies.

Common myths about psychoanalysis

“Psychoanalysis is only about childhood.”

Early relationships and experiences matter, and analysis also focuses closely on present life. The central question concerns how past experience remains psychologically active in current relationships, expectations, emotional reactions, self-understanding, and ways of coping.

“The analyst just sits silently.”

That image comes partly from older traditions and popular culture. Contemporary analytic practice varies considerably. Analysts may ask questions, make observations, challenge assumptions, explore what is happening between patient and analyst, and participate actively in trying to understand the patient’s experience.

“Psychoanalysis is basically Freud’s original theory.”

Freud founded psychoanalysis, and the field has undergone more than a century of revision, disagreement, research, and theoretical development. Contemporary analysts draw on ideas about relationships, attachment, development, trauma, culture, gender, sexuality, embodiment, and the ways two people influence one another in treatment.

What is psychoanalysis trying to change?

Symptom relief matters. Someone who is depressed wants to feel less depressed; someone who is anxious wants less anxiety; someone caught in painful relationships wants those relationships to change.

Psychoanalysis also asks what psychological organization keeps producing the problem.

A symptom may be connected to deeper patterns of protecting oneself, expectations formed in earlier relationships, difficulties recognizing or tolerating particular feelings, conflicts between different wishes, or assumptions about oneself and other people that operate largely outside awareness. Psychoanalysis attempts to understand these patterns in enough depth that change becomes more than knowing what one “should” do.

The hope is to have more room to be oneself, with greater freedom to think, feel, relate, and choose.

Considering psychoanalysis

Beginning psychoanalysis does not require already knowing that it is the treatment you want. The first meetings are an opportunity to talk about what brings you in, consider what you hope might change, and determine whether psychoanalysis, another form of psychotherapy, or another treatment approach seems most appropriate.

Psychoanalysis is demanding, and for the right person it can offer something relatively unusual in contemporary mental health care: time, continuity, and sustained attention to the complexity of a life alongside attention to symptoms.

Dr. Sehrbrock is a psychoanalytic candidate at the Toronto Institute of Contemporary Psychoanalysis (TICP). Contact Dr. Sehrbrock to learn more.

Further Resources

If you are interested in learning more, you may be interested in these resources:

In the book The Examined Life, psychoanalyst Stephen Grosz draws on decades of clinical work to tell a series of brief, engaging stories about people trying to understand themselves and the patterns that shape their lives. Written without technical jargon, the book offers an accessible glimpse into how psychoanalysis works: through careful listening, curiosity, and attention to meanings and connections that may not initially be obvious.

The Examined Life

The Toronto Psychoanalytic Society’s What Is Psychoanalysis? video offers a clear, brief introduction to contemporary psychoanalysis for people who may be unfamiliar with it. It explains central ideas such as unconscious patterns, speaking freely, the role of the analyst, and how psychoanalysis can help people better understand recurring emotional and relational difficulties in their lives.

References

Beutel, M. E., Krakau, L., Kaufhold, J., Bahrke, U., Grabhorn, A., Hautzinger, M., Fiedler, G., Kallenbach-Kaminski, L., Ernst, M., Rüger, B., & Leuzinger-Bohleber, M. (2023). Recovery from chronic depression and structural change: 5-year outcomes after psychoanalytic and cognitive-behavioural long-term treatments (LAC depression study). Clinical Psychology & Psychotherapy, 30(1), 188–201. https://doi.org/10.1002/cpp.2793

de Maat, S., de Jonghe, F., de Kraker, R., Leichsenring, F., Abbass, A., Luyten, P., Barber, J. P., Van, R., & Dekker, J. (2013). The current state of the empirical evidence for psychoanalysis: A meta-analytic approach. Harvard Review of Psychiatry, 21(3), 107–137. https://doi.org/10.1097/HRP.0b013e318294f5fd

Huber, D., Henrich, G., Clarkin, J. F., & Klug, G. (2013). Psychoanalytic versus psychodynamic therapy for depression: A three-year follow-up study. Psychiatry, 76(2), 132–149. https://doi.org/10.1521/psyc.2013.76.2.132

Knekt, P., Lindfors, O., Laaksonen, M. A., Renlund, C., Haaramo, P., Härkänen, T., Virtala, E., & Helsinki Psychotherapy Study Group. (2011). Quasi-experimental study on the effectiveness of psychoanalysis, long-term and short-term psychotherapy on psychiatric symptoms, work ability and functional capacity during a 5-year follow-up. Journal of Affective Disorders, 132(1–2), 37–47. https://doi.org/10.1016/j.jad.2011.01.014

Knekt, P., Heinonen, E., & Lindfors, O. (2018). Follow-up of the effectiveness of long-term psychodynamic psychotherapy and psychoanalysis 5 years after the end of psychoanalysis: Minor differences in psychiatric symptoms and work ability. Neurology, Psychiatry and Brain Research, 30, 163–166. https://doi.org/10.1016/j.npbr.2018.10.003

Leuzinger-Bohleber, M., Stuhr, U., Rüger, B., & Beutel, M. (2003). How to study the ‘quality of psychoanalytic treatments’ and their long-term effects on patients’ well-being: A representative, multi-perspective follow-up study. The International Journal of Psychoanalysis, 84(2), 263–290. https://doi.org/10.1516/C387-0AFM-4P34-M4BT

Lindfors, O., Knekt, P., Lehtonen, J., Virtala, E., Maljanen, T., & Härkänen, T. (2019). Effectiveness of psychoanalysis and long-term psychodynamic psychotherapy on personality and social functioning 10 years after start of treatment. Psychiatry Research, 272, 774–783. https://doi.org/10.1016/j.psychres.2018.12.082