In Debate
Does Psychoanalysis Have a Future? Yes.
Glen O Gabbard1
(Can J Psychiatry 2005;50:741–742)
Click here for author affiliations.
The answer to the question posed in this debate is both simple and complex. The simple answer is, “Of course it does.” In an era of quick-fix cures, biological reductionism, and alarming invasions of privacy by electronic data banks that store medical records, a consumer backlash has emerged. Psychoanalysts today are consulted by people who want to make meaning out of their lives. They want a setting where their unique sense of personhood can be recognized, listened to, and validated. They want to tell their own story at a pace that allows the complexity, conflict, and ambivalence of the human psyche to unfold in their own time and in their own idiosyncratic way. Moreover, in the US, many patients pay for psychoanalysis out of their pockets to avoid the compromises of confidentiality that accompany monitoring of treatment by third parties who work for insurance companies. In this regard, psychoanalysis can be considered the last bastion of true privacy (outside the confessional). One can say whatever comes to mind without concerns about political correctness, adverse consequences to one’s relationships, or the shameful humiliation that often accompanies the revelation of one’s most egregious transgressions. The power of empathic understanding when one anticipates judgmental condemnation cannot be overstated.
What analysts know—and patients soon learn—is that the verbal narrative unfolding in the course of analysis is only part of the clinical picture. What the patient cannot remember and verbalize in the consulting room will be unconsciously enacted in the relationship with the analyst again and again, providing a source of data that will be of considerable value in the eventual understanding of the patient’s problems. The “how to” of relatedness is encoded in procedural memory, and the patient unconsciously recreates the internal world of relationships in front of the analyst’s eyes. Data about the patient’s desires, hopes, fears, and conflicts that are outside of conscious awareness become manifest in the day in, day out repetitions of analytic work. Patients who come to analysis seek a level of understanding that they know will not be available in briefer or more consciously directed treatments. These patients often bristle at the categorization of their struggles as a discrete diagnostic entity, and they may balk at a symptom-tailored treatment that bypasses who they are as a person.
The complex answer to the question posed by this debate is something like the following, “Yes, but the exact shape of that future is unclear.” Applications of psychoanalysis are thriving. Psychoanalytic theory informs many departments in the academy, including literature, film, and studies of society and culture. Basic premises of psychoanalytic thought are receiving confirmation from neuroscience. The idea that much of mental life is unconscious has been well established by extensive research (1), and the fundamental psychoanalytic notion that people actively try to forget unwanted past experiences has been confirmed by a recent functional magnetic resonance imaging study (2).
To be sure, the field of psychoanalysis has made a series of historical errors. Among these were the concept of the “schizophrenogenic mother” in the case of schizophrenia and the “refrigerator mother” in the case of early infantile autism. These are egregious examples of the privileging of psycho-analytic developmental theory over empirical research. Indeed, many psychoanalysts have been guilty of arrogance and complacency that has led them to a contemptuous attitude toward rigorous scientific investigation that can only be described as “Don’t bother me with the facts—I’ve already made up my mind.” This historical smugness hampered the development of systematic psychoanalytic research.
While there is no doubt that psychoanalysis is badly in need of scientific evidence demonstrating its effectiveness as a treatment, there are also significant incompatibilities between the methods of science and psychoanalysis. As Fonagy and colleagues note,
The making of meaning around a life narrative is fundamental to human nature. It is therefore inconceivable that psychoanalysis (or a process very much like it) will ever not be part of the range of approaches that people with mental health problems desire. However, in this context, success is measured as eloquence (or meaningfulness), which is not reducible to either symptom or suffering (3, p 4).
Psychoanalysis is perhaps the only treatment that is not primarily geared to symptom removal, so the paradigm of evidence-based medicine presents a host of problems for studying the efficacy of psychoanalysis (4). Self-selection of treatment in long-term therapy or analysis is of critical importance. Random assignment might well lead to high rates of drop out. A suitably matched control group would be difficult to recruit given the length of the treatment. The cost of a study that might easily take over a decade to complete could be prohibitive. Uncontrolled variables, such as illness, life events, and medication changes might complicate the interpretation of the results.
Moreover, the empirically validated therapies movement has resulted in a backlash challenging the wisdom of this model for psychotherapy studies (5). In brief, these efficacy studies, which are more suited to pharmacotherapy trials, fail to address the needs of real patients in real-world settings with complex comorbidities and entrenched psychopathology.
Derivatives of psychoanalysis, such as brief psychodynamic psychotherapy, are much less formidable to study, and a recent metaanalysis documents the efficacy of this modality for various psychiatric disorders (6). Longer-term variants of analytic therapy for personality disorders have also been subjected to randomized controlled trials with encouraging results (7–9).
In spite of the challenges posed by the task of designing useful and convincing outcome studies of psychoanalysis, investigations from Europe have been collecting data for some time (10). They have the potential to demonstrate whether psychoanalysis achieves changes beyond what is possible with psychodynamic psychotherapy. The Stockholm Outcome of Psychotherapy and Psychoanalysis Project was launched in 1993 and followed patients, prospectively in psychotherapy and psychoanalysis so that a comparison was possible. The psychoanalysis and psychotherapy patients began with almost identical levels of pathology, but in analyzing the results, the investigators found that, after treatment termination, analysands continued progressively to improve, whereas the mean outcome flattened out asymptotically after psychotherapy (11). In measurements of symptomatic outcome with the Symptom Checklist-90, improvement during the 3 years after treatment was positively related to treatment frequency and duration, with patients in psychoanalysis doing better than those in psychoanalytic psychotherapy. There is a measure of irony in finding superior symptomatic improvement from a treatment that is not geared to symptom removal.
Of great interest in this study is that a strict, classical psychoanalytic attitude did not seem to be as effective as a more flexible one. Indeed, the approach to psychoanalytic treatment has changed dramatically since the time of Freud. It is ironic that many of the attacks on psychoanalysis (12,13) have critiqued a model of psychoanalysis that resembles 1890’s Freud rather than the current Zeitgeist of psychoanalytic practice. Would one critique modern aviation by focusing on the Wright brothers?
While I could review other data that are highly supportive of the value of psychoanalytic treatment, I wish to close my position statement with another observation. Only psychoanalytic understanding can really address why the question posed by this debate raises such passion in people. We read in the popular press on a regular basis that psychoanalysis is dead. It appears that the moribund patient needs to be resurrected on a regular basis so it can be killed off again. The notion that we are consciously confused and unconsciously controlled will always be threatening. The intensity with which psychoanalysis is repeatedly challenged reflects this underlying anxiety. The future of psychoanalysis will involve a more sophisticated understanding of who should receive it and under what circumstances, but it will most certainly survive. Psychoanalysis remains the most comprehensive model of the human mind.
References
1. Westen D. The scientific status of unconscious processes: Is Freud really dead?
J Am Psychoanal Assoc 1999;47:1061–106.
2. Anderson MC, Ochsner KN, Kuhl B, Cooper J, Robertson E, Gabrieli SW and others. Neural systems underlying the suppression of unwanted memories. Science 2004;303:232–5.
3. Fonagy P, Roth A, Higgitt A. Psychodynamic psychotherapies: evidence-based practice and clinical wisdom. Bull Menninger Clin 2005;69:1–58.
4. Gabbard GO, Gunderson JG, Fonagy P. The place of psychoanalytic treatments within psychiatry. Arch Gen Psychiatry 2002;59:505–10.
5. Westen D, Morrison K, Thompson-Brenner H. The empirical status of empirically supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. Psychol Bull 2004;130:631–63.
6. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic therapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry 2004;61:1208–16.
7. Bateman AW, Fonagy P. The effectiveness of partial hospitalization in the treatment of borderline personality disorder—a randomized controlled trial. Am J Psychiatry 1999;156:1563–9.
8. Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an 18-month follow-up. Am J Psychiatry 2001;158:36–42.
9. Svartberg M, Stiles TC, Selzer MH. Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Am J Psychiatry 2004;161:810–7.
10. Richardson P, Kachele H, Renlund C, editors. Research in psychoanalytic psychotherapy with adults. Karnac, London; 2004.
11. Sandell R, Bloomberg J, Lazar A. Time matters: on temporal interactions in psychoanalysis and long-term psychotherapy. Psychotherapy Research 2002;12:39–58.
12. Crews F. The memory wars: Freud’s legacy in dispute. New York: New York Review of Books; 1995.
13. Grunbaum A. The foundations of psychoanalysis: a philosophical critique. Berkeley (CA): Univ of California Press; 1984.
Author(s)
Manuscript received and accepted July 2005.
Brown Foundation Chair of Psychoanalysis and Professor of Psychiatry, Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030
Address for correspondence: Dr G Gabbard Baylor, College of Medicine, 1 Baylor Plaza, Houston TX 77030
e-mail: ggabbard@bcm.tmc.edu
|
