Wendy spent five years in psychoanalysis, delving so deeply into her mind that she could no longer see the connection between her adult problems and her teenage episodes of "cutting" her wrists. After she and her analyst had their final session, during which he welcomed her to move on with her life, Wendy was not completely happy, but she was happier than she ever had been. And that, psychologists say, is successful therapy.

Psychoanalysis probes the unconscious mind to unlock the mysteries that drive conscious emotions and behavior. The discipline is built on pillars set by Sigmund Freud a century ago. It is characterized by frequent sessions that can take place over many years, wherein patients are encouraged to freely associate whatever comes to mind as the analyst sits quietly and listens.

Today the practice is changing. The transformation is in part the result of a better understanding of what works during self-analysis. But increasingly, psychotherapy is changing just to survive, held hostage to limits on insurance coverage determined by managed care companies and facing replacement by psychoactive drugs that in the long run are far cheaper than a patient's weekly visit to the therapist's office. In this incarnation, it suddenly matters less that symptoms may disappear without patients figuring out the underlying cause.

Harsh Reality
To keep psychoanalysis alive, contemporary therapists are revamping Freud's theories. They have discarded some traditional beliefs and have loosened requirements so patients can succeed in fewer sessions. Many analysts are even talking to their patients and sharing their own thoughts and feelings, a practice that Freud said would complicate the treatment process.

Some experts chafe at the changes, however. They say that short-term therapy can be successful for some problems such as phobias but does not work for personality disorders, chronic depression and other substantial mental illnesses. They claim that managed care companies make decisions based on cost, not on any science that shows what works best for a specific condition. Insurance companies argue that patients can do just as well on medication as they can with talk therapy and that for talk, "short term" is enough.

Extended analysis certainly is under siege. Today patients having long-term psychotherapy--more than 20 sessions--account for only 15 percent of those who seek treatment, according to a study in the American Journal of Psychiatry. Psychoanalysts contend that it takes longer to work out issues that have been shaped by a lifetime of emotion and experience, yet they know they must compete in a magic-pill era in which people may be content to have their symptoms disappear without much thought to why they emerged in the first place.

"A better understanding of the self is needed for a better recovery," asserts Gail Saltz, a Manhattan analyst and author of Becoming Real (Riverhead Trade, 2005), a book about the benefits of analysis. She says that there are still people who lie on the couch four times a week, but many analysts have accepted a once-a-week regimen. And although studies have shown that certain patients progress better when therapy is frequent, Saltz believes once a week can still be successful. Psychologists have at least agreed that even long-term analysis should be completed within four years.

Regardless of frequency, Saltz says, the goal is to help patients "better tolerate the ups and downs of life" or, as Freud put it, "get beyond everyday human misery." Freud developed his ideas before scientists knew much about the brain's workings, however, and today some of his once popular theories about human development are seen as simply wrong.

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