What has meaning in our lives? Why do we make the decisions we do? How do we choose our friends, our lovers, our jobs? When we lie to ourselves, how do we get at our authentic “truth”? The answer, according to psychoanalysts, is straight-forward: Free Associate! This means exercising the mind in an unrestrained way to determine what pops in and out at any given moment. For example, sitting in traffic, it is curious what thoughts arise to consciousness? Frustration, anger, acceptance, or imaginative thinking? Thinking about thinking takes time, and effort, and in the presence of a therapist, can present issues of shame and guilt. Sexual thoughts, greedy thoughts, competitive thoughts, can all bring a sense of unworthiness to the relationship, and as such, those thoughts can be suppressed leading to feelings of conscious anxiety without known antecedents. The hallmark of psychoanalytic work is allowing time, and openness to see what the patient brings to the relationship, which is in stark contrast to the “T” therapies (such as CBT, DBT, IPT) in which the therapist has an agenda. The lack of an agenda is KEY to understanding the meaning that patients’ assign to the experiences in their lives. The other KEY is time and patience. For patients to free associate, they must speak without fear of judgment, and this can only happen in the context of a trusting and reliable relationship. This “frame” as you will, provides an opportunity for patients to feel safe to “free associate” since free associating is a scary activity. Being afraid of one’s own brain is the hallmark of anxiety disorders, and as such, to make friends with one’s thoughts is a journey of self-discovery and self-acceptance. The length of this journey is not knowable from the outset, and hence restrictions on the number of psychotherapy visits is simply absurd. Thought suppression, the hallmark of Cognitive Behavioral Therapy (CBT) is antithetical to thought acceptance in that thought suppression might provide temporary relief, in the longer term, buried thoughts resurface in ways that can be more disturbing and more unpredictable, whereas free association offers the promise of a more sustaining treatment in that the technique helps the patient cope with whatever uncomfortable thoughts come to mind. The point here is not to say that CBT is bad for everyone but rather to say that it is not good for everyone, and should not be a one size fits all approach to anxiety disorders and/or depression. Psychopharmacology is another intervention for anxiety/depression, and as such, medication can facilitate free association in that the patient may feel more relaxed in order to allow his brain to connect seemingly unrelated ideas. Hence medication can be a tool which eases the psychotherapeutic process, a benefit of medication which is usually not touted. In summary, it is the loss of free association in psychotherapy which saddens me. The restriction of thought takes away both a deeper relief in patients and a deeper sense of work satisfaction in the provider. Superficial treatments bring superficial results and thereby superficial feelings of job satisfaction. Deeper treatments bring the opposite. We have deeper treatments to offer patients, but as I have said many times, as a field, we have lost our way and forgotten about that.