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.

High on the list is that infants have complicated sexual desires. Peter D. Kramer, a Massachusetts psychiatrist who popularized the new generation of antidepressants in his best-selling book Listening to Prozac (Penguin, 1993), says that “there is no evidence that infants have sexual desires.” Kramer notes that although Freud believed that adult complaints of childhood sexual abuse stemmed from such childhood fantasies, the evidence today is plain that sexual abuse of children is common, affecting up to 20 percent of girls and 10 percent of boys.

Freud also had little to offer the therapist in understanding trauma, which experts now know can cause lifelong problems. Trauma therapy is a relatively new field, built on work with war veterans. Post-traumatic stress disorder is a hot topic in psychotherapy today, one that was poorly addressed before, Kramer notes, because it was not possible to have effective treatment when the theoretical underpinnings were shaky.

Friend, Not Father

Readdressing the basic tenets of psychoanalysis has led to perhaps the most radical change of all: modern psychologists are actually talking to their patients. Freud's original “transference” theory demanded that an analyst remain quiet and aloof so as to serve as a “screen” onto which the patient could project her emotions. But therapists are now sharing more of themselves. “How can I remain opaque when my clients can go online and learn that I love Greek music?” asks psychoanalyst Spyros D. Orfanos, clinic director in psychoanalysis at New York University.

Orfanos says that today's analyst is not an authoritative father figure but a partner in figuring out “the powerful emotional forces that drive behavior.” He thinks that having a dialogue with a patient is the best way to work toward change. Many analysts also now agree that empathy is key to the relationship, and empathy requires engagement, not just listening.

Psychoanalysis is also changing in the face of steady competition from other forms of help, such as cognitive behavioral therapy, in which patients try to change certain troubling behaviors, and goal-oriented therapy, which lays out ways to attain, say, certain kinds of relationships. These practices may or may not touch on the patient's past. And to hold its own, psychoanalysis is shedding its image as a privileged treatment for the wealthy; so-called training centers are popping up everywhere that provide low-cost appointments.

Scientists are also attempting to study the biology of the analysis process itself. At New York–Presbyterian Hospital/Weill Cornell Medical Center, psychiatrists Otto F. Kernberg and David A. Silbersweig are recording brain scans of patients before and after analysis. Such studies may help end the debate over the effectiveness of lengthy treatment, notes Kramer, who recently published Against Depression (Viking Adult, 2005), an assessment of mood disorders. “We don’t know what works or what doesn’t work.”

Orfanos is dubious about scanning, maintaining that analysis is a humanistic endeavor that does not necessarily fit into a biology-based medical model. “It's about understanding how your mind works,” he says, “so that you can have more choices in your life.”