An Evidence-Based Critique of Contemporary Psychoanalysis

Research, Theory, and Clinical Practice

Joel Paris

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9780429665325
• Topic: Medicine
• Subtopic: Clinical Psychology

An Evidence-Based Critique of Contemporary Psychoanalysis assesses the state of psychoanalysis in the 21st century. Joel Paris examines areas where analysis needs to develop a stronger scientific and clinical base, and to integrate its ideas with modern clinical psychology and psychiatry.

While psychoanalysis has declined as an independent discipline, it continues to play a major role in clinical thought. Paris explores the extent to which analysis has gained support from recent empirical research. He argues that it could revive its influence by establishing a stronger relationship to science, whilst looking at the state of current research. For clinical applications, he suggests while convincing evidence is lacking to support long-term treatment, brief psychoanalytic therapy, lasting for a few months, has been shown to be relatively effective for common mental disorders. For theory, Paris reviews changes in the psychoanalytic paradigm, most particularly the shift from a theory based largely on intrapsychic mechanisms to the more interpersonal approach of attachment theory. He also reviews the interfaces between psychoanalysis and other disciplines, ranging from "neuropsychoanalysis" to the incorporation of analytic theory into post-modern models popular in the humanities.

An Evidence-Based Critique of Contemporary Psychoanalysis concludes by examining the legacy of psychoanalysis and making recommendations for integration into broader psychological theory and psychotherapy. It will be of great interest to psychoanalysts, psychoanalytic psychotherapists, and scholars and practitioners across the mental health professions interested in the future and influence of the field.

Part I
Psychoanalysis and science

Chapter 1
Psychoanalysis in decline

Psychoanalysis has had an enormous impact on clinical practice and modern culture. Yet over the last few decades of the century, its theory and practice have undergone a notable decline (Hale, 1995; Paris, 2005). Thirty years ago, it was already evident that analytic ideas were having much less impact on academic and clinical psychology (Westen, 1999). While these trends have long been in place, they have not been reversed. This is a dramatic change from the time when psychoanalysis was a strong leader in psychological science and mental health treatment (Paris, 2005).

In the US, while the total numbers of psychoanalysts in practice have not declined, psychiatrists are much less likely to become candidates in institutes, and the body of trainees is increasingly dominated by PhD psychologists. Candidates with a Master’s level training in social work or nursing are also accepted. Moreover, candidates can enter training without degrees in any field related to mental health. The website of the American Psychoanalytic Association (www.apsa.org) mentions, among others, professions of educator, business consultant, historian, biographer, neuroscientist, and author. This is a major change from a time when most analysts had to have a medical degree. But opening up admission to institutes was necessary given major changes in who was willing to apply.

In my own field of psychiatry, there was a time when an analytic training was an important credential – one that was held by many chairs of university departments. Today department chairs tend to have a background in neuroscience. In the ten years (1997–2007) that I was chair of psychiatry at McGill University, and in the following decade, only one faculty member with training in psychoanalysis was hired on faculty, and there have been none since. (This is not because academic psychiatry discriminates against psychoanalysts, but because medical graduates are no longer inclined to seek this kind of training.)

The situation in psychology is in some ways even more discouraging for analysts. Even at the undergraduate level, abnormal psychology is no longer taught, as it once was, as a branch of psychoanalytic theory. And while psychodynamic approaches are still important for those who choose to be clinical psychologists, cognitive behavioral approaches are more prominent. Thus, although the large number of PhD graduates is enough to fill slots for analytic training, few of these programs encourage their graduates to become analysts or hire faculty who are likely to promote that option.

How can we explain the decline of a field whose ideas once dominated psychology, psychiatry, and related mental health disciplines? Several issues are in play. The first, related to a major theme of this book, is the intellectual isolation of a movement that trains prospective analysts in free-standing institutes that are not part of universities, and that do not encourage research (Kernberg, 2011, 2015). The guru-disciple relationship that tends to develop in a training analysis works against the adoption of scientific skepticism and a commitment to empiricism. A second issue is that psychoanalytic theory has had difficulty fitting its model into contemporary theory and research in psychology. That situation is not new (Fisher and Greenberg, 1996), but change has been very slow. A third issue is that psychoanalytic treatment, in its classical form, is expensive and relatively inaccessible.

Today, papers on psychoanalysis only occasionally appear in non-psychoanalytic journals, and research papers are rarely published in psychoanalytic journals. The pages of the two major journals in the field, the International Journal of Psychoanalysis and the Journal of the American Psychoanalytic Association, both sponsored by official psychoanalytic organizations, are almost entirely devoted to theoretical reviews, suggestions for practice, or case histories. Psychoanalytic Psychology, published by the American Psychological Association, does publish research, but its pages are still dominated by papers based on theory and/or case histories. Psychoanalytic Inquiry, published by Taylor and Francis, has shown interest in research, but most of its articles still lie outside the mainstream of psychology. The same can be said of the other journals related to psychoanalysis (Psychoanalytic Quarterly, Psychoanalytic Review, Psychoanalytic Inquiry, American Journal of Psychoanalysis, Contemporary Psychoanalysis, Psychodynamic Psychiatry, and the Canadian Journal of Psychoanalysis).

In retrospect, the isolation of psychoanalysis from other psychological disciplines was a serious error. The decision, originally made by Freud, was an understandable reaction to rejection of his ideas in academic circles. However, the dramatic rise of psychoanalysis in America (Hale, 1995) was a missed opportunity to develop a research culture. Today, with the important exception of attachment theory, little effort has been made to integrate psychodynamic theory into the paradigms that have become standard in developmental psychology. Psychoanalysis is also out of step with broader biosocial models, such as gene-environment interactions. As for practice, psychoanalytic therapy has played only a minor role in the psychotherapy integration movement.

Another trend is the move of medicine, psychiatry, and clinical psychology towards a commitment to evidence-based practice (Spring, 2007; Wallace, 2011). This trend implies that all treatments need to be validated by clinical trials, and further evaluated in meta-analyses. Practice should be based on what these data show. But since the time of Freud, psychoanalysis lacked a strong research tradition. Clinical experience is not a sufficient basis on which to offer complex and expensive forms of treatment.

A few psychoanalysts with PhD-level training in research methodology, such as the University of London professor Peter Fonagy (2015), have provided strong leadership in empirical investigation. Even so, as one can see from the content of journals, research remains outside the culture of analysis. This is one of the main reasons why the theory and practice of psychoanalysis, which have not been well supported by scientific evidence, need radical revision.

However, many of the formulations originally proposed by Freud have been quietly dropped. For this reason, the large literature of “Freud criticism” is not a useful way to examine the contemporary scene (Westen, 1999). Psychoanalysis in the 21st century has come to focus on concepts more strongly supported by research: understanding of the unconscious mind, and the relationship between life experiences and psychopathological symptoms.

A third issue in the decline of psychoanalysis is that the niche once assigned to psychoanalysis has been filled by competing methods, most particularly cognitive behavioral therapy (CBT; Beck, 1986). Moreover, CBT made great efforts, from the very beginning, to be evidence-based. CBT is the legacy of Aaron Beck (1986), a psychoanalyst who proposed this method as simpler, briefer, and researchable. Beck’s commitment to science, leading to thousands of research studies, is largely responsible for the current reputation of CBT. Even so, CBT does not deserve its reputation as a method whose efficacy depends on the administration of specific technical interventions. As we will see, psychotherapies based on entirely different theories tend to produce very similar results (Wampold, 2001). But they have not all been studied as extensively as CBT. Actually, CBT does not come out as nearly as efficacious as it claims when the research literature is examined in detail (Wollfolk, 2010). But at least it has a tradition of respecting research findings from which psychoanalysis can learn.

A fourth problem concerns the length of treatment. When psychoanalysis was new, it was not that expensive, but it became more and more costly over time, particularly as the length of treatment increased. Today classical methods, with multiple weekly sessions over many months or years, are not affordable for all but a few of those who seek mental health treatment. This is an important reason why psychoanalytic treatment needs to be shortened and streamlined.

Research consistently shows that treatment with only a few months of psychodynamic therapy has a strong base in evidence (Leichsenring et al., 2004; Abbass et al., 2014). Recently, many people were surprised to learn that Pope Francis had seen a psychoanalyst in Argentina. But what the Pope described as analytic treatment was six months of once weekly sessions.

A fifth and closely related issue concerns the accessibility of treatment. Psychoanalysis continues to be practiced, mainly in large cities, but serves a small clientele who are willing to undergo a lengthy treatment. As documented decades ago in a book by the journalist Janet Malcolm (1981), practitioners, even in New York City, cannot easily make a living though psychoanalysis alone. In any case, psychoanalysis is not suitable for all patients. Here is how the website of the American Psychoanalytic Association (www.apsa.org/) describes who should seek this kind of treatment:

The person best able to undergo psychoanalysis is someone who, no matter how incapacitated at the time, is basically, or potentially, a sturdy individual. This person may have already achieved important satisfactions – with friends, in marriage, in work, or through special interests and hobbies – but is nonetheless significantly impaired by long-standing symptoms: depression or anxiety, sexual incapacities, or physical symptoms without any demonstrable underlying physical cause. One person may be plagued by private rituals or compulsions or repetitive thoughts of which no one else is aware. Another may live a constricted life of isolation and loneliness, incapable of feeling close to anyone. A victim of childhood sexual abuse might suffer from an inability to trust others. Some people come to analysis because of repeated failures in work or in love, brought about not by chance but by self-destructive patterns of behavior. Others need analysis because the way they are – their character – substantially limits their choices and their pleasures. And still others seek analysis definitively to resolve psychological problems that were only temporarily or partially resolved by other approaches.

This description suggests that patients who are severely impaired are probably not suitable for analytic therapy, at least in its classical form. Instead, psychoanalysis seems to market itself for improving quality of life in people who are closer to normal than many of the patients seen in most clinics. Given the great demand for care for serious and disabling mental illness, this niche is too narrow, and helps account for the decline of the field. If a shortened and streamlined version of psychoanalysis is equally effective, the niche could be much wider.

Underlying all these problems, a sixth issue is the epistemological method of psychoanalysis. The use of case histories to support clinical theories runs a great danger of “confirmation bias”, i.e., imposing previously held beliefs on the observation of phenomena (Sutherland, 2007). For this reason, clinical illustrations are no substitute for efficacy and effectiveness research on outcome, or for process research on the mechanisms behind therapeutic results. To put it another way, we now live in an era where accountability trumps authority. In an article on why clinical trials of psychoanalytic treatment are necessary, Eagle and Wolitsky (2012, p. 793) comment:

For the most part, at least until recently,… calls for accountability and systematic research have gone unheeded. Although a smattering of psychoanalytic research was carried out over the years, only during the last two decades or so has there emerged a small but significant cadre of researchers who have focused on psychoanalysis and psychoanalytic treatment – virtually all of whom, it should be noted, are associated with universities rather than free-standing psychoanalytic institutes. However, neither the calls for research over the years nor the recent emergence of significant psychoanalytic research has had much impact on psychoanalytic training.

The most serious problem with relying on case histories is that they are, almost without exception, used to confirm conclusions rather than to disconfirm them. Great efforts always need to be made in science to keep confirmation biases out of research. Even in clinical trials, one can find “allegiance effects” in which investigators are more likely to report good outcome for the kind of therapy to which they already adhere (Luborsky et al., 1999).

In 2009 the British Journal of Psychiatry published a debate about whether the journal should accept psychoanalytic case reports (Wolpert and Fonagy, 2009). Wolpert, a biologist, argued that case reports should be excluded because they are not scientific. Fonagy, while conceding some of these points, defended analysis on the grounds that research is possible and is beginning to be conducted. But while Fonagy is strongly committed to science, he represents a small minority in a field which has notably lacked such a commitment. All too many analysts are still satisfied with papers that present theoretical arguments backed up by detailed reports about specific cases. Even worse, quite a few practitioners (e.g., Hoffman, 2009) see little need for research that fails to take a psychoanalytic perspective on clinical material.

In summary, the problem is that psychoanalysis has, up to recently, failed to build bridges with empirical sciences that could have provided it with needed intellectual fertilization. It has rejected reformulations of its theories that are based on data, so that had once been radical and new threatened to become conservative and stifling. A vast intellectual gulf between research and practice has emerged, in which psychoanalysts do no research, and in which its practitioners rarely read scientific journals that lie outside their field.

The problem goes back to Freud, who was satisfied with deriving theories from clinical inference. His attitude was not unusual at the time, as there was no such thing as evidence-based practice as we currently understand it. But standards are different today. Moreover, the philosopher Adolf Grunbaum (1984) noted t...

Table of contents

• Cover
• Half Title
• Series Page
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Introduction
• PART I Psychoanalysis and science
• PART II The boundaries of psychoanalysis
• Index