Who Consults Depth Psychotherapists?
A Plethora of Presenting Problems (Vol. 1, Issue 2)
The number of potential topics to address, particularly in the first issue of an ongoing newsletter, proves mind-boggling. Innumerable topics about psychoanalysis, psychoanalytic psychotherapy, and depth therapy to mind. Further, the breadth of interests bringing you readers to this weekly newsletter—psychotherapists, patients, and anyone interested in psychology and philosophy—is nearly overwhelming.
One must begin somewhere, and thus I start by offering an overview of the types of persons likely to consult depth psychotherapists.
Because unlike, say, patients of physicians, many without diagnosable mental health conditions seek help from psychoanalytic psychotherapists. In the ensuing paragraphs, I describe the range of patient presentations. Then, I offer several ideas for categorizing them and, perhaps more importantly, ways to organize the work across all patient presentations.
Most people know when to turn to a physician, an attorney, or an accountant.
Most have no idea when to consult a depth psychotherapist.
Outside psychoanalysts cloistered consulting rooms, the lay public remains woefully ignorant of the nature of such work. When hearing the word, psychoanalysis, most imagine Sigmund Freud, smoking a cigar seated behind a patient lying on a couch, furiously scribbling notes. International trends towards using CBT in combination with psychotropic medication are easily explained and clearly understood.
In contrast, psychoanalysis remains vague and ambiguous. In a forthcoming newsletter, I will carefully describe the meaning of the term, psychoanalysis. Meanwhile, and as I noted in my first missive, terms and phrases like psychoanalyst, depth psychotherapist, psychodynamic psychotherapist, or psychoanalytic psychotherapist essentially denote the same thing. I shall use them interchangeably.
In the way of a preview, and extremely briefly, these psychotherapies combine exploration of childhood experiences, review of themes in patients’ current lives, and studies of the actual psychotherapist-patient relationship as a means of transformation. This triad, known as TCP (for transference, current, and past), runs through all depth psychotherapeutic modalities.
As just noted, many patients suffer diagnosable mental health conditions addressed in classification systems like the DSM-V or the ICD-10. Cascading into depth psychotherapists consulting rooms with conditions ranging from generalized anxiety disorder to schizophrenia, they seek symptom-relief.
However, ever since psychoanalysis emerged as a distinct profession in 1897, patients have sought assistance from psychoanalysts for other reasons. Foucault (1970) acknowledges the arbitrary nature of classification systems and, with that as disclaimer, here are a few categories of patients without psychiatric diagnoses seeking help:
Some individuals consult psychodynamic psychotherapists when faced with with personal losses ranging from serious medical diagnoses to the death of loved ones.
Others want assistance in wrestling with developmental transitions like adolescence, middle-age, or old age.
Many seek help specifically with relationships. They have been unable to find romantic love; they may feel trapped in troubled relationships; they may have, in general, difficulty with interpersonal intimacy.
Another category concerns exposure to trauma not severe enough to meet the criteria for post-traumatic stress disorder (PTSD). These persons may feel haunted by a sexual assault, by a physical injury with accompanying disability and pain, or by involvement in nerve-wracking litigation.
Again, this list is necessarily incomplete. You can probably think of several other categories of individuals who consult you. If you’re a patient, other reasons why you sought the help of a psychoanalyst probably come to your mind.
Here are three ways to think about psychotherapeutic goals, regardless of presenting problem.
Lacan (1960) brilliantly summarized psychoanalytic work as involving a process of “subjectification” (Fink, 1995, p. 70). In brief, depth psychotherapy processes strive to transform the ego into the subject. The ego represents who you think you are, how you’ve been shaped by parents or by society. You’ll see if commonly in individuals, many of whom you may personally know, who take refuge in identifying themselves as fathers, as doctors, as workaholics or as losers.
Regardless of their theoretical orientations, depth psychotherapists strive to dismantle such rigid ego-identifications and replace them with the sense of being vibrant subjectivities. They liberate patients from ways they might have been objectified. They help them achieve greater levels of authenticity. Consider just one of the above-noted categories, namely problems encountered with normal life transitions.
Most adolescents struggle with rapid shifts in identity. Erik Erikson (1980), who identified a series of dialectical tasks defining the process of development over life, calls adolescents’ struggle one of identity versus role confusion. Their parents might insist they remain highly academically-focused, preparing themselves for stable careers in medicine, law, or accounting. In contrast, the teenagers themselves might feel attracted to the arts. Their authentic interests lie in painting, sculpture, or writing. They experience a clash between the demands of their parents and their own “inner voice.”
Closely related to this idea of subjectification, just briefly explained, would be the idea of integration. This hypothetical adolescent, for example, might also want to authentically avoid five years of starvation in Paris, a la Picasso. Instead, they’re on a journey to integrate society’s demands with their aesthetic leanings. The depth psychotherapist would listen carefully to the various sides of this patient, helping him or her find a unifying path forward.
Finally, and another idea for broadly defining what it is that psychoanalytic psychotherapists do, I have proposed the phrase, transformational encounters (Karbelnig, 2014, 2018ab). These could be defined as a single psychoanalytic session, or a long set of them. Critics have objected to the phrase’s vagueness. For example, personal change can occur as a result of work, i.e. an emergency medical technician saving a life. It may happen from love, i.e. transcendent sexual activities, or even from play, i.e. the ecstacy experienced by practitioners of extreme sports.
But, when applied specifically to the uniquely interpersonal psychoanalytic relationship, the phrase transformational encounters fully encompasses the possibilities of what occurs in the course of depth psychotherapy. Whether suffering physical and mental symptoms, relationship difficulties, occupational stressors or any variety of existential crises, and whether or not meeting the criteria for diagnosable mental disorders, psychoanalytic patients share a universal interest in personal transformation. They need some change, even if only in their relationships with themselves, i.e. less intense self-criticism, acceptance of a loss, or venting anger over a betrayal.
I bring this first newsletter to a close feeling humbled by the potential number of topics before me. Thus far, I have introduced readers to the weekly missive. In this contribution, I attempted to define what all psychoanalytic psychotherapists aim to provide, namely subjectification or integration. I also introduced a way to think of psychoanalytic sessions as a unique form of transformational encounter.
Please know I have no prepared list of topics because, I fear, they approach the infinite. I aim to provide knowledge, again, for practitioners ranging from the beginner to the seasoned, for patients of depth psychotherapists, and for all of you fascinated by the endless complexity of the mind. I thank you for your interest, and I appreciate your tolerance as I find my way through the labyrinth of potential subjects.
Erikson, E.H. (1980). Identity and the life cycle. New York: Norton.
Fink, B. (1995). The Lacanian subject: Between language and jouissance. Princeton, NJ: Princeton University Press.
Foucault, M. (1970). The order of things: An archeology of the human sciences. A. Sheridan, translator. New York, NY: Vintage Books.
Sartre, J-P. (1984) Being and nothingness: a phenomenological essay on ontology. Trans. H. Barnes. New York: Washington Square Press. (Original work published in 1943).
Karbelnig, A. M. (2014). The sanctuary of empathy and the invitation of engagement: psychic retreat, Kafka’s “A Hunger Artist,” and the psychoanalytic process. The Psychoanalytic Review.101(6):895-924.
Karbelnig, A. M. (2018a) A perilous high wire act: framing psychoanalytic relationships with severely traumatized patients. The Psychoanalytic Quarterly, 87:3, 443-478.
Karbelnig, A. M. (2018b) Addressing psychoanalysis’s post-tower of babel linguistic challenge: a proposal for a cross-theoretical, clinical nomenclature. Contemporary Psychoanalysis, 103(1): 69-109.
Lacan, J. (1960). The seminar of Jacques Lacan, book IV: The ethics of psychoanalysis. Trans. D. Porter; Ed by J. A. Miller. New York, NY: Norton.