Outcome Research and the Future of Psychoanalysis

Clinicians and Researchers in Dialogue

Marianne Leuzinger-Bohleber, Mark Solms, Simon E. Arnold, Marianne Leuzinger-Bohleber, Mark Solms, Simon E. Arnold

• Publisher: Routledge
• Year: 2020
• Print ISBN: 9781032174662
• eBook ISBN: 9781000026672
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Outcome Research and the Future of Psychoanalysis explores the connection between outcome studies and important and complex questions of clinical practices, research methodologies, epistemology, and sociological considerations. Presenting the ideas and voices of leading experts in clinical and extra-clinical research in psychoanalysis, the book provides an overview of the state of the art of outcome research, its results and implications. Furthermore, its contributionsdiscuss the basic premises and ideas of outcome research and in which way the contemporary Zeitgeist might shape the future of psychoanalysis.

Divided into three parts, the book begins by discussing the scientific basis of psychoanalysis and advances in psychoanalytic thinking as well as the state of the art of psychoanalytic outcome research, critically analyzing so-called evidence-based therapies. Part II of the book contains exemplary research projects that are discussed from a clinical perspective, illustrating the dialogue between researchers and clinicians. Lastly, in Part III, several psychoanalysts review the importance of critical thinking and research in psychoanalytical education.

Thought-provoking and expertly written and researched, this book is a useful resource for academics, researchers and postgraduate students in the fields of mental health, psychotherapy, and psychoanalysis.

Chapter 1

The scientific basis of psychoanalysis

Introductory remarks

Mark Solms

My aim is to set out what we psychoanalysts may consider to be the core scientific claims of our discipline.¹ Such stock-taking is necessary due to widespread misconceptions among the public, and disagreements among ourselves regarding specialist details, which obscure a bigger picture upon which we can all agree. Agreement on our core claims, which enjoy strong empirical support, will enable us better to defend them against the prejudice that psychoanalysis is not “evidence-based.”

I shall address three questions: (A) How does the emotional mind work, in health and disease? (B) On this basis, what does psychoanalytic treatment aim to achieve? (C) How effective is it? My arguments in relation to these questions will be:

A Psychoanalysis rests upon three core claims about the emotional mind that were once considered controversial but which are now widely accepted in neighbouring disciplines.

B The clinical methods that psychoanalysts use to relieve mental suffering flow directly from these core claims, and are consistent with current scientific understanding of how the brain changes.

C It is therefore not surprising that psychoanalytic therapy achieves good outcomes—at least as good as, and in some important respects better than, other evidence-based treatments in psychiatry today.

A

Our three core claims about the emotional mind, I submit, are the following: (1) The human infant is not a blank slate; like all other species, we are born with a set of innate needs. (2) The main task of mental development is to learn how to meet these needs in the world, which implies that mental disorder arises from failures to achieve this task. (3) Most of our methods of meeting our emotional needs are executed unconsciously, which requires us to return them to consciousness in order to change them.

These core claims could also be described as premises, but it is important to recognize that they are scientific premises, because they are testable and falsifiable. As I proceed, I will elaborate these premises, adding details, but I want to differentiate between the core claims themselves and the specifying details. The details are empirical. Whether they are ultimately upheld or not does not affect the core claims. Detailed knowledge changes over time, but core claims are foundational. Everything we do in psychoanalysis is predicated upon these three claims. If they are disproven, the core scientific presuppositions upon which psychoanalysis (as we know it) rests will have been rejected. But as things stand currently, in 2018, they are eminently defensible, strongly—indeed increasingly—supported by accumulating and converging lines of evidence in neighbouring fields. This continues to justify Kandel’s (1999) assertion that “Psychoanalysis still represents the most coherent and intellectually satisfying view of the mind.”

I turn now to each of the proposed three claims.

CLAIM 1. The human infant is not a blank slate; like all other species, we are born with a set of innate needs. These needs are regulated autonomically up to a point, beyond which they make “demands upon the mind to perform work,” as Freud (1915) put it. Such mental demands constitute his “id.” They are ultimately felt as affects. That is why affect is so important in psychoanalysis. The affect broadcasting a need releases reflexive or instinctual behaviours, which are hard-wired predictions (action plans) that we execute in order to meet our needs—e.g., we cry, search, freeze, flee, attack. Universal agreement about the number of innate needs in the human brain has not been achieved,² but most mainstream taxonomies (e.g., Panksepp, 1998) include at least a subset of the following emotional ones:³

• We need to engage with the world—since all our biological appetites (including bodily needs like hunger and thirst) can only be met there.⁴ This is a foraging or seeking instinct. It is felt as interest, curiosity and the like. (It coincides roughly but not completely with Freud’s concept of “libido”; see Solms, 2012.)

• We need to find sexual partners. This is felt as lust. This instinct is sexually dimorphic (on average) but male and female inclinations exist in both genders. (Like all other biological appetites, lust is channelled through seeking.)

• We need to escape dangerous situations. This is fear.

• We need to destroy frustrating objects (things that get between us and satisfaction of our needs). This is rage.

• We need to attach to caregivers (those who look after us). Separation from attachment figures is felt not as fear but as panic, and loss of them is felt as despair. (The whole of “attachment theory” relates to this need, and the next one.)

• We need to care for and nurture others, especially our offspring. This is the so-called maternal instinct, but it exists (to varying degrees) in both genders.

• We need to play. This is not as frivolous as it appears; play is the medium through which social hierarchies are formed (“pecking order”), in-group and out-group boundaries are maintained, and territory is won and defended.

CLAIM 2. The main task of mental development is to learn how to meet our needs in the world. We do not learn for its own sake; we do so in order to establish optimal predictions as to how we may meet our needs in a given environment. This is what Freud (1923) called “ego” development. Learning is necessary because even innate predictions have to be reconciled with lived experience. Evolution predicts how we should behave in, say, dangerous situations in general, but it cannot predict all possible dangers (e.g., electrical sockets); each individual has to learn what to fear and how best to respond to the variety of actual dangers. The most crucial lessons are learned during critical periods, mainly in early childhood, when we are—unfortunately—not best equipped to deal with the fact that our innate predictions often conflict with one another (e.g., attachment vs rage, curiosity vs fear).⁵ We therefore need to learn compromises, and we must find indirect ways of meeting our needs. This often involves substitute-formation. Humans also have a large capacity for delaying gratification and for satisfying their needs in imaginary and symbolic ways.

It is crucial to recognize that successful predictions entail successful emotion regulation, and vice-versa. This is because our needs are felt. Thus successful avoidance of attack reduces fear, successful reunion after separation reduces panic, etc., whereas unsuccessful attempts at avoidance or reunion result in persistence of the fear or panic, etc.

CLAIM 3. Most of our predictions are executed unconsciously. Consciousness (short-term “working memory”) is an extremely limited resource, so there is enormous pressure to consolidate learnt solutions to life’s problems into long-term memory, and ultimately to automatize them (for review see Bargh & Chartrand, 1999, who conclude that only 5% of goal-directed actions are conscious). Innate predictions are effected automatically from the outset, as are those acquired in the first two years of life, before the preconscious (“declarative”) memory systems mature (cf. infantile amnesia). Multiple unconscious (“non-declarative”) memory systems exist, such as “procedural” and “emotional” memory, which operate according to different rules. These stereotyped systems (cf. the repetition compulsion) bypass thinking (i.e., the secondary process) and define the system unconscious.

The following fact is of utmost importance. Not only successful predictions are automatized. With this simple observation, we overcome the unfortunate distinction between the “cognitive” and “Freudian” unconscious (Solms, 2017). Sometimes a child has to make the best of a bad job in order to focus on the problems which it can solve. Such illegitimately or prematurely automatized predictions (i.e., wishes as opposed to realistic solutions) are called “the repressed.” In order for predictions to be updated in light of experience, they need to be “reconsolidated”; that is, they need to enter consciousness again, in order for the long-term traces to become labile once more (Nader et al., 2000; Sara, 2000; Tronson & Taylor, 2007). This is sometimes difficult to achieve, however; not least because procedural memories are “hard to learn and hard to forget” and some emotional memories—which can be acquired through just a single exposure—appear to be indelible; but also because the essential mechanism of repression entails resistance to reconsolidation despite prediction errors. The theory of reconsolidation is very important for understanding the mechanism of psychoanalysis. This leads to my second argument, concerning our treatment.

B

My second argument is that the clinical methods that psychoanalysts use to relieve mental suffering flow from the above core claims, which are consistent with current understanding of how the brain changes. The argument unfolds over three steps:

a Psychological patients suffer mainly from feelings. The essential difference between psychoanalytic and psychopharmacological methods of treatment is that we believe feelings mean something. Specifically, feelings represent unsatisfied needs. (Thus, a patient suffering from panic is afraid of losing something, a patient suffering from rage is frustrated by something, etc.) This truism applies regardless of etiological factors; even if one person is constitutionally more fearful, say, than the next, or cognitively less capable of updating predictions, their fear still means something. To be clear: emotional disorders entail unsuccessful attempts to satisfy needs. That is, psychological symptoms (unlike physiological ones) involve intentionality.

b The main purpose of psychological treatment, then, is to help patients learn better ways of meeting their needs. This, in turn, leads to better emotion regulation. The psychopharmacological approach, by contrast, suppresses unwanted feelings. We do not believe that drugs that treat feelings directly can cure emotional disorder; drugs are symptomatic (not causal) treatments. To cure an emotional disorder, the patient’s failure to meet underlying need/s must be addressed, since this is what is...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Notes on contributors
• Introduction: outcome research and the future of psychoanalysis
• 1 The scientific basis of psychoanalysis: introductory remarks
• PART I: Outcome research: state of the art
• PART II: Research and clinical practice in dialogue
• PART III: Critical thinking and research in psychoanalytic education
• Index