who not only provides interpretations that will lead
to insight but also guides the patient into new
learning situations seems more likely to achieve last-
ing solutions to the patient’s problems than does a
therapist who relies solely on insight (or solely on
behavior, for that matter).
It seems clear that a major reason for the rapid
rise of the behavioral therapies was the failure of so
many psychotherapists to deal directly with the spe-
cific problems of the patient. The approach inevita-
bly seemed to be one of relegating the presenting
problem to the status of a“symptom of something
deeper.”The therapist then began working with
that“something deeper”while clinging to the abid-
ing belief that once the patient understood it, the
symptom or deficit would disappear. Unfortu-
nately, things did not work out that way often
enough. In any case, more and more therapists are
trying to foster both insight and behavioral alterna-
tives in their patients.
The Economics of Psychotherapy
By its very nature (reconstruction of the personal-
ity), psychoanalysis is a long and costly procedure.
Its course over 3 to 5 years and the long and costly
preparation of its practitioners ensure that it will be
an expensive undertaking. Even more contempo-
rary psychodynamic therapy approaches involve
1 – 2 sessions per week for one or more years.
Consequently, it has become a therapy for the afflu-
ent—for those who have both the money and the
time to pursue the resolution of their neuroses.
Moreover, the procedures of psychoanalysis are
such that only relatively intelligent, sophisticated,
and educated groups are likely to be able to accept
the therapeutic demands it makes. For all these rea-
sons, only a small portion of those in need of psycho-
therapy are likely to be reached by traditional
psychoanalysis. The poor, the undereducated, minor-
ity groups, older populations, the severely disturbed,
and those beset by reality burdens of living for which
they are woefully unprepared will in all likelihood
not become psychoanalytic patients.
For these reasons alone, many regard psycho-
analysis as a failure. It is inherently incapable of
putting even a dent in the mental health problems
of the nation. Yet, for persons who have the nec-
essary personal qualities and financial resources, psy-
choanalysis has been sometimes helpful, particularly
for those whose problems can best be met through
the development of understanding.
Psychoanalytic techniques seem to have helped
many patients, and as a theory of therapy, psychoanal-
ysis undergirds many forms of psychotherapy. Yet
many clinicians still question whether, after all these
years, there is really much in the way of definitive
research evidence for its effectiveness. These senti-
ments are echoed by Wolpe (1981). Although hardly
unbiased, Wolpe is particularly critical of a method that
can allow patients to remain so long in therapy, often
with little evidence of improvement. Wolpe cites
examples offered by Schmideberg (1970). In one
case, a 54-year-old man hadbeen in psychoanalysis
for 30 years without noticeable improvement.
Awomanwhobeganpsychoanalysiswithnospecific
symptoms later developed agoraphobia and after
12yearsoftherapywasworsethanwhenshebegan.
Admittedly, nearly every brand of therapy contains its
share of horror stories. Butlengthy therapy combined
with little improvement does raise questions.
It is encouraging, however, that brief forms of
psychodynamic psychotherapy have been devel-
oped. Recent meta-analyses indicate that brief psy-
chodynamic treatments that incorporate the use of
manuals show stronger treatment effects (versus
psychodynamic treatments that do not use manuals)
and in some cases may be equivalent to other forms
of brief psychological treatment (Crits-Christoph,
1992). Furthermore, as we discussed earlier, recent
reviews of the treatment literature do provide at
least some tentative research support for the use of
psychodynamic treatment with certain clinical
populations (Cuijpers et al., 2011; Gibbons et al.,
2008). In addition to providing encouragement to
psychodynamically oriented clinicians, this finding
should serve to impel them toward mastery and
the use of manual-based, empirically supported
brief psychodynamic treatments, such as interper-
sonal psychotherapy (IPT; Markowitz, 1998). This
approach is both scientifically defensible and appeal-
ing to managed care companies.PSYCHOTHERAPY: THE PSYCHODYNAMIC PERSPECTIVE 365