A clinical psychologist-psychoanalyst in Madrid

Before a psychotherapeutic treatment can be undertaken, it is necessary to reach an accurate diagnosis; in order to achieve this, between three to five diagnostic and assessment interviews are done, with some individual variations, in the following way.

The first interview is an opportunity for the patient and therapist to touch base and for the patient to express the reasons that have led him or her to consult, what symptoms he or she suffers from currently, what their evolution has been, and ask any questions that he or she may have.

In the following interviews  the patient will be invited to speak as spontaneously as possible about his or her life such as, for instance,  family history, childhood and adolescence, important relationships, events that have had an impact, self-concept, and goals and expectations for the future. Dream activity, somatic illnesses and medication (if taken), will also be explored.

This material provides the therapist with essential information in order to reach a diagnosis and the interview process also gives the patient time to see if he or she feels comfortable with the psychologist and can imagine working with him.

In the last interview the therapist will give the patient feedback about what he has observed and will indicate what modality of treatment (see Psychotherapy and Psychoanalysis) is the most appropriate for his or her situation.

There are two different levels at which this question must be answered: the mental level and the neurological level.  

At the mental level we observe that as patients acquire deep emotional understanding of themselves they have more mental instruments to modify their way of being, feeling and behaving so that these may be beneficial to their quality of life. Knowing oneself implies undoing sterile behavioral patterns, dissolving chronic symptom formations, discovering new potentialities, allowing oneself to satisfy deep needs, and knowing how to take care of the more vulnerable aspects of the self.  

At the neurological level recent investigations in neuropsychiatry using computerized axial tomography (CAT) and nuclear magnetic resonance (NMR) have shown that the synaptic structure, the density of certain neuron bundles and the prevalence of particular neurotransmitters in the brain change during psychotherapy. These results were to be expected since a person’s mind is not an abstract entity separated from the body, but rather the result of the extraordinarily complex interaction between physical parts of the brain.

For the moment, the exact mechanisms that mediate between the self-knowing process of psychotherapy and the structural changes in the brain’s inner architecture are unknown, but the empirical data indicate that they exist. As research continues we will learn more.

The setting consists of all those variables that constitute the formal frame within which the treatment will develop: appointment scheduling, frequency and duration of the sessions; fees and modes of payment; and the dates of interruptions for vacations. The stability and constancy of the setting have not only an organizing function but are also essential for the treatment's efficacy.

Although it is not a perfect analogy, there is a situation familiar to almost everyone that illustrates this therapeutic function clearly. When a doctor prescribes an antibiotic to fight an infection, she indicates to the patient that he must take it at set hours in order to maintain the therapeutic concentration of the antibiotic in the blood in order for it to combat the pathogenic agent. There is no pathogenic agent in the mind, naturally, but it is essential to preserve the same and stable concentration of therapeutic work in the patient's mind for it to work effectively.

There is another reason why it is important to maintain the stability of the setting. The setting functions as an invariable element from which to observe the variables (and thus understand more) in the patient's life. If the setting were also variable, it would be much more difficult to know what the events in the patient's life are due to.

Treatment can take place one, two, three, four or five times a week. The increase in weekly frequency brings with it an increase in the intensity, nuance and depth of the work.

The frequency of sessions is not necessarily an indicator of the severity of the patient's difficulties, but the increased frequency of sessions facilitates the surfacing and containment of unconscious mental contents, as well as their careful processing afterwards.

As a general rule, from three sessions a week upward the couch is usually used and the conjunction of the frequency of the sessions with the patient lying on the couch tends to facilitate a deeper psychoanalytic process. One way to express the difference, at the therapeutic level, between a low number of sessions per week and a high number of sessions per week is the difference that there is between trying to understand the life of someone you see in photographs or trying to understand the life of someone you see in a film where she/he is the main character. Psychoanalysts are specifically trained to work with the highly complex and deep material that appears at a high frequency of sessions.

For certain patients whose tolerance for closeness is very low when they consult, a high frequency of sessions per week may initially be counter-indicated, but, in general, psychotherapy/psychoanalysis is like any other discipline: the more you work, the better the chances of achieving significant changes. It must also be taken into account that there are certain situations that require a minimum number of weekly sessions in order for the patient to get better and it wouldn't be effective to work below that minimum. All this will be assessed by the psychologist-psychoanalyst during the interviews. 

The face-to-face setting is a familiar and known context for patients: it allows them to see the psychoanalyst and to feel visually accompanied. This can be a valuable setting when the patient's internal support is not sufficiently stable, and he or she needs the real visual presence of the other to sustain him or herself emotionally. The disadvantage of face-to-face work is that the actual visual presence of the psychoanalyst tends to limit the patient's associative freedom, as he/she is likely to modify what he/she says according to how he/she sees the psychoanalyst responding (despite psychoanalysts' best efforts at neutrality) .

The couch can be a useful work instrument to give the patient greater freedom to be in contact with himself instead of paying attention to the therapist. It also allows the patient to talk about important material that is difficult to express when you are face to face with someone. The couch shares with the high frequency of sessions the function of intensifying, nuancing and deepening the work since it allows the patient to have a much closer experience of himself without being distracted by the therapist and what she does. The minimum frequency of sessions to work on the couch are three per week and the maximum are five. The benefit, or not, of the use of the couch will be assessed by the psychologist-psychoanalyst during the sessions.

However, the use of the couch is not always indicated for the same reasons that a high frequency of sessions isn't, nor is it recommended for patients for whom the visual loss of the therapist is too disorganizing. In these cases, it will be more beneficial for the patient to be able to physically see the therapist and sit face to face. This kind of work can be done from once to five times a week.

The development of psychotropic drugs in the fifties meant an enormous advance in psychiatry, and allowed many patients to go back to a decent quality of life. Since then, research in the field has developed considerably and the new generations of drugs are more effective and have fewer side effects.

Psychotropic drugs act on brain chemistry, modifying the intensity, the transmission frequency and the interaction of neurotransmitters in order for the patient’s affective state to improve. They are the fastest remedy that exists to reduce symptom intensity, but they do no have long-term effects. If they are the patient’s only therapeutic means, it is probable that when he or she stops taking them the old symptoms will reappear, unmodified. With certain exceptions, every pharmacological treatment must be secondary to a psychotherapy whose goal is to produce stable long-term change.

The use of medication is indicated when the intensity of the symptoms is such that the patient cannot take on his or her minimum obligations, such as work or family life. A psychiatrist or a psychologist can assess the need for medication, but only a psychiatrist can prescribe. If a psychologist should consider that medication is indicated he will refer the patient to a psychiatrist. Efforts will be made for medication use to be limited in time until the patient is well enough to be able to take on her or his life without it.

Current research with monozygotic twins that have been separated at birth suggests that the answer lies in an extremely complex interaction between certain organic ––genetic or epigenetic–– factors, and the environment. The more serious the emotional problems, the more it seems that there may exist certain predispositions towards that pathology. A predisposition is not determining and only results in pathological development if it is combined with an unfavorable environment.

The goal of psychoanalytic psychotherapy is not just symptom relief, but the consolidation within the patient's mind of solid resources in order to be able to live ––enjoying it, finding meaning and being able to bear inner or exterior difficulties–– in the long term without therapeutic help.

These resources can be, amongst others, the capacity to have more satisfactory relationships, to make more effective use of one's own potential, to maintain a realistic sense of self-esteem, to tolerate a wide range of affects, to understand oneself and others in a complex and sophisticated way, and being able to face life's challenges with greater freedom and flexibility.

Given that the human mind is one of the most hyper-complex, and idiosyncratic, objects of study that exists, its careful exploration cannot be fast. The time needed to understand oneself, to comprehend where emotional problems come from, to recognize counter-developmental relational patterns and bring about the necessary changes usually implies some years.

Adult psychotherapy finishes when both the patient and the therapist agree that the patient enjoys a quality of life that is good for her and that she has acquired the inner capacity for this to continue to be the case without therapeutic help.

Child and adolescent psychotherapy finish under the same conditions as that of adults except that three parties must agree: the patient, the parents and the therapist.

The material with which the patient and the analyst are going to work in order to understand what is happening to the patient is everything that goes through the patient's mind (see Adults) including any idea, or curiosity, that she may have about the analyst.

Since the patient does not know real facts about the analyst (apart from legitimate information about training and experience), she is free to imagine or think whatever she wishes and precisely that which she imagines or thinks is a valuable source of information to understand how the patient sees and interprets the world. The way in which the patient organizes and defines an ambiguous stimulus (the unknown analyst) is informative as to how her mind functions. If the analyst talks about himself, he blocks the patient's capacity to imagine with a concrete reality about himself that reduces the scope of the material that they can work with.

That said, it is entirely normal for the patient to be curious about the therapist and, although he will not reply directly to the curiosity, they will be able to think together about what that specific curiosity means for that patient, what she imagines and thus enrich their knowledge of how the patient's mind functions.

Psychiatrist: This is a person who has undertaken higher studies in medicine, specializing in psychiatry, the discipline that is geared towards the prevention, evaluation, diagnostic, treatment and rehabilitation of mental disorders. In order to be a clinical specialist, a psychiatrist in Spain will have done the MIR residency training program in the Public Mental Health sector. The fundamental difference between a psychologist and a psychiatrist is that the latter has been trained to recognize medical conditions that could be affecting the patient’s mental state, and, as a doctor she or he can prescribe medication if necessary. If a psychiatrist should also practice as a psychotherapist, he or she will have undergone long and exacting training in one of the schools of psychotherapy.

Clinical Psychologist: This is a person who has undertaken higher studies in psychology, the discipline that studies the behavior and the mental processes of human beings and animals. She or he will have specialized in the clinical branch of psychology, which is the field that directs the study, diagnosis and treatment of psychological problems or disorders in order to increase the patient’s wellbeing, emphasizing the search for knowledge. A psychologist in Spain will also have done a PIR residency training program in the Public Health sector, or an equivalent program in the private mental health sector. He or she will also have undergone long and exacting training in one of the schools of psychotherapy.

Psychotherapist: This is a person that has undertaken higher studies in psychiatry, psychology, or, sometimes, social work, and who works to alleviate the emotional suffering of patients. He or she will also have undergone long and exacting training in one of the schools of psychotherapy. There currently exist many branches of psychotherapy, though they all spring from five main schools: psychoanalysis, systemic therapy, humanistic therapy, behaviorism and cognitivism. These schools have training programs of differing intensity and depth.

Psychoanalyst: This is a person who has undertaken higher studies in psychiatry, psychology, or sometimes, adjacent disciplines, and that has undergone long and exacting training in the psychotherapeutic modality called psychoanalysis. Psychoanalysis is a discipline that was created by Sigmund Freud (1856-1939) in order to help patients discover the unconscious reasons for their difficulties and, thus, free themselves of them. Psychoanalysis has developed enormously since its creation, and there currently exist many schools specialized in extremely precise aspects of mental functioning.

Preliminary interviews and sessions both of psychotherapy and psychoanalysis last 45 minutes.

The fees of psychologists in Madrid range from 70€ to 250€ per session / consultation. Permiliminary interviews and consultations are billed.

Certain insurance companies will reimburse a number of sessions per year depending on the policy the holder has. In order to be reimbursed, the policy holder will have to provide her/his insurance company with a full bill, issued by the psychologist, with a bill number, address and NIF (número de idenfiticación fiscal).

This page of the American Psychological Association contains complete information on the matter.