Clinical psychoanalysis in the 20th century can roughly be divided up into three periods or phases. In the early part of the century, psychoanalysis was in its infancy, with many experiments and changes in theory. In the middle of the century, American psychoanalysis became obsessed with rules, and was called, 'classical,' 'orthodox,' and 'traditional.' This was mainstream psychoanalysis at the height of its power and prestige. Orthodox psychoanalysis is what psychiatric residents were taught, and they were encouraged to undergo personal analysis in order to be able to do in-depth psychotherapy, uncovering psychotherapy, which was recommended for almost all psychiatric conditions, including psychoses and the affective disorders.
As clinical psychoanalysis has evolved, many of these rules were dropped or given flexibility. As examples, the couch was not always used, and sometimes the analyst would allow information from other sources, such as members of the family. It was not necessary to have 4-5 sessions a week; 1-3 sessions might work. Instead of 50 minute sessions, 45 minute sessions were introduced. On the other hand, recent analytic writers have related good effects from seeing some patients for two hours at a time.
The middle of the century saw the advent of group analysis, where analysands would meet together for at least an hour and a half, sometimes extending to three hour sessions and ultimately ‘marathon’ sessions lasting eight to twelve hours a day for as many as three days. Many of these groups regressed to the power of suggestion and directives of the analyst-leader, but there are some which retained the identical principles of individual analysis, and only encouraged regression in the service of the ego.
According to Freud, the therapy is psychoanalysis if the technique used is free-association, and the conceptual framework includes knowledge of the structure of the unconscious. It is psychoanalysis if the therapist is mostly silent and occasionally facilitates the process by nonverbal and verbal behavior, such as nodding, saying, “uh, huh,” asking questions, making clarifications and ultimately interpretations. What makes it psychoanalysis, according to Freud, is that there is an analysis of the resistance and transference. This should lead to 'working-through' of unresolved childhood conflicts. Adding Wilhelm Reich's emphasis, the characterological resistance must also be worked through, to get down to the deeper layers of the unconscious.
The latter part of the 20th century saw the loss of primacy and prestige of formal, traditional psychoanalysis. Too many analysts were considered to be psychologically arrogant and emotionally detached, a position which helped some analysands, but not others. Stories abounded about failure of treatment, especially with manic-depressives, schizophrenics and obsessive-compulsives. Eventually, pharmacological research led to psychotropic medications which dramatically improved these conditions. Psychoanalysis was not the panacea that the people had wished for. Psychoanalytically-oriented psychotherapy covered the larger ground of people who needed therapy, but not necessarily traditional psychoanalysis.
Given the modifications in psychoanalysis developed over the years, other techniques were developed. My own modifications of traditional psychoanalysis include the face-to-face interpersonal doctor-patient relationship according to Harry Stack Sullivan and others, plus the analytic group. Patients were selected as suitable for psychoanalysis and a therapeutic relationship established. What developed was a 'working alliance' and a positive transference relationship.
I then proceeded in certain cases to advise entering into group analysis, in addition to the individual. I said the added feedback from other analysands would heighten the development of insight, that there was much value from the reactions of other people in therapy besides the therapist. An atmosphere of openness and safety was sought, and the technique of free-association in the group became spontaneous interaction. This gave the group ample material for analysis, and often the interpretation for one became useful for another. I have a long list of patients who underwent this modification of traditional psychoanalysis with a high percentage of beneficial analytic change, including characterologic modification.
I would expect to supply clinical vignettes to illustrate the method, demonstrating multiple transferences, group resistance and interpretation within the group.