Introduction to the Practice of Psychoanalytic Psychotherapy

Alessandra Lemma

• Éditeur: Wiley-Blackwell
• Année: 2015
• ISBN:
  9781118818527
• Édition: 2
• Sujet: Psicología
• Sous-sujet: Psicoterapia

The 2nd Edition of Introduction to the Practice of Psychoanalytic Psychotherapy, the highly successful practice-oriented handbook designed to demystify psychoanalytic psychotherapy, is updated and revised to reflect the latest developments in the field.

• Updated edition of an extremely successful textbook in its field, featuring numerous updates to reflect the latest research and evidence base
• Demystifies the processes underpinning psychoanalytic psychotherapy, particularly the development of the analytic attitude guided by principles of clinical technique
• Provides step-by-step guidance in key areas such as how to conduct assessments, how to formulate cases in psychodynamic terms and how to approach endings
• The author is a leader in the field – she is General Editor of the New Library of Psychoanalysis book series and a former editor of Psychoanalytic Psychotherapy

1
Brave New Worlds: A Psychoanalysis Fit for the Twenty-First Century

Psychoanalysis is a very robust animal. Psychoanalytic thinking has vibrancy and depth. It is, in my opinion, the most intellectually satisfying view of the mind. Yet psychoanalysis, despite recent advances, is still in crisis.

To a lay audience, and even to some well versed in psychoanalytic assumptions, the psychoanalyst is often seen as the one peddling ideas that are best laid to rest. Attempts to expose analytic ideas and the practice of psychoanalytic approaches to scientific evaluation are sometimes viewed with suspicion by some psychoanalytic clinicians. Psychoanalysis has traditionally adopted an arrogant attitude even towards other therapeutic models. At best, they are tolerated. At worst, they are regarded with a degree of contempt that perhaps masks a fear of the “other”. A colleague once humorously captured this fear as she described psychoanalysis' view of Cognitive-behavioural Therapy (CBT) as “Darth Vader's therapeutic arm”. To be fair psychoanalysis too is regarded by some CBT therapists in an equally irrational manner.

Psychoanalytic theory has traditionally evolved around the hearsay evidence of the treating therapist. As each therapist accumulates the so-called evidence, it becomes the grounds for establishing the truthfulness of psychoanalytic assumptions on the basis of a well-known logical error, namely, the argument of past co-occurrence. This refers to the logical fallacy of assuming that if it has happened once before, for example, if a patient expressed his anger by turning it into depression, and if this same pattern is observed again, this means that the theory is correct, that is, depression is anger turned inwards. This argument is compelling, but it has little probative value. Generally speaking, as clinicians we find it hardest to identify negative instances when the patient's reaction is not as we would have hypothesised it to be on the basis of the specific hypotheses or theories that guide our work.

The historical insularity of psychoanalysis and its inward-looking attitude have meant that until comparatively recently, it has lacked the kind of perspective that tempers omnipotence. Although research in psychoanalysis is ongoing, it is by no means yet a well-integrated activity within its own field. Psychoanalytic therapy trainings, on the whole, teach psychoanalytic ideas with little more than token reference to research, viewing the latter as largely redundant to an understanding of the mind or the practice of psychotherapy. Exchange with other disciplines, such as neuro-psychoanalysis, that might provide other kinds of corroborative evidence of our therapeutic efforts have also aroused varying degrees of resistance.

The prevailing attitude to empiricism generally is questionable as if to invite science into the debate about the validity of analytic theories, or the effectiveness of psychoanalytic interventions, is equivalent to selling the analytic soul to the devil. To argue, as some psychoanalytic clinicians do, that psychoanalysis is not a science and that it is therefore meaningless to evaluate it by the standards of other scientific endeavours merely sidesteps a critical issue: if psychoanalysis and psychoanalytic therapy are treatments for psychological problems, we have a responsibility to ensure that we understand how they work and check if they are effective. I am far from being a diehard experimentalist: if psychoanalysis only claimed to be a philosophy, for example, experimental validation would not be an issue. Heidegger's or Nietzsche's views about human nature are important and help us think about ourselves and our lives. But neither Nietzsche nor Heidegger set themselves up to formally treat psychological problems, though they have a great deal to say about human nature that is enlightening. It is because psychoanalysis claims to be a treatment for psychological problems and it seeks public funding for its provision that we have a responsibility to evaluate its effectiveness notwithstanding the limitations of the methodologies currently available to us.

Having criticised psychoanalysis' ambivalent relationship to science, it is also important to address the narrow-minded conceptualisation of science espoused by the critics of psychoanalysis. The debate about the scientific status of psychoanalysis is by now well worn and circular. As Fonagy reminds us:

Many disciplines are accepted as sciences, even if quantification is not instrumental and experiments are not possible to repeat as in palaeontology. Newton's theory is not falsifiable. Moreover, it is evidence that beyond a certain point of generality a theory is not possible to “prove”; it can only be accepted or not as organising a wide array of facts.

(Quoted in Fonagy et al., 1999)

Science is all too often idealised as the only respectable path to knowledge. Yet, scientific endeavour is anything but neutral or dispassionate. Behind the statistics proving one theory and disproving another lie researchers fuelled by deep passions, as Luborsky (1999) highlighted in his study that showed how we could predict the conclusion of a paper on psychotherapeutic outcome just by knowing the theoretical orientation of its first author. This caution should not deter us, however, from exploring what may be helpful in the empirical tradition to the future of psychoanalysis.

Psychoanalysis allows us to make conjectures about the human mind. Many of these are hard to test empirically. Psychoanalytic concepts are complex, but complexity is not a good enough reason to avoid operationalising our terms. There is little doubt – in my own mind at least – that psychoanalysis could try harder to operationalise its terms so that those gifted enough to find ingenious ways of researching concepts could do so more productively, and thereby provide an empirical base to psychoanalysis as a theory. In the absence of a more established empirical base, allegiances to particular theories develop because we are “grabbed” by an idea or because our psychoanalytic education has been conducted “in an atmosphere of indoctrination” (Kernberg, 1986: 799). The theories we subscribe to are then used to justify what we do with our patients.

All knowledge is subject to both rational and irrational forces. It is vital to counter some of the more simplistic notions about the status of scientific findings. Equally, however, if all knowledge is vulnerable to unconscious forces this alerts us to the fact that our “clinical knowledge” is similarly compromised so that from whatever perspective we approach the task of “understanding” a phenomenon we invariably need another perspective to act as a kind of corrective. Research can provide one such “other” perspective for the clinician, just as the clinician can alert the researcher to potential blind spots in his or her scientific field of vision.

Needless to say, adopting a scientific, rigorous approach to one's work does not necessarily entail personally engaging in research trials. However, I firmly believe that it is incumbent on all therapists, psychoanalytic or otherwise, to regard being familiar with research as one of the responsibilities inherent in our professional role. If you are in any doubt about this, ask yourself what your expectations would be of a doctor. Would you trust his recommendations knowing that he was only well read on a few doctors who practised a hundred years ago, or if he could not answer you in an informed manner about why he was opting for one procedure over another or could not tell you if his chosen intervention had been shown to be effective? Let us not forget that psychotherapy is a powerful tool, all the more so because we as yet understand so little about how it works.

Given the relative paucity of research on the effectiveness of specific psychoanalytic interventions, this book would be on the thin side if I restricted myself to presenting only those techniques supported by research. Incidentally, this would also be the case for a book on other types of psychotherapy. The fact that CBT has received good support from the psychotherapy outcome literature does not imply that we know which key interventions make a difference. If anything, what research suggests is that some of the key interventions associated with good outcome are those techniques that are traditionally associated with psychoanalytic practice (see Chapter 2).

So … Does It Work? Examining the Evidence Base for Psychoanalytic Psychotherapy

There is, as we know, more evidence for cognitive behaviour therapy than for psychoanalytic psychotherapy. Of course, absence of evidence is not evidence of ineffectiveness. Moreover, there is some evidence now and the evidence base has increased since the first edition of this book.

In the current climate in the public health sector, research and psychoanalysis need to become better acquainted with each other because evidence-based practice, as a primary driver in healthcare, is here to stay. We have to engage with the demand this places on us as providers of psychoanalytic psychotherapy and demonstrate that what we offer can make a distinctive, effective contribution to Public Mental Health. The demand for public accountability urges us, with unprecedented force, to consider whether we want the psychoanalytic body of knowledge and its applications to be a relic of historical interest or at the cutting edge of mental health care.

Engagement with this demand requires that we try out different ways of doing things, which may feel alien to established practice (e.g. session-by-session outcome monitoring), and to many may seem altogether irrelevant to what transpires in the therapeutic situation. Arguably this also requires that we actively respond to this external culture from a vantage point that is distinctively psychoanalytic and practice-based so that we are not just “complying” with what we feel is imposed on us (though sometimes we have to do that too, of necessity), but rather we also contribute to the discourse about the varieties of scientific research, and the contributions and limitations of different kinds of methodologies.

If we look back at the history of psychotherapy research, it becomes apparent that psychoanalytic interventions have been competing in research trials where the changes measured are typically not relevant to the overarching goals of psychoanalysis and are better suited to those targeted by a medical intervention. Measures for the most part are arbitrary, but in an evidence-based practice culture they are considered to correspond to something of self-evident value in the outside world (Kazdin, 2006). But we do well to question the real-life significance of changes on many of the symptom questionnaires used to evaluate outcome. Arbitrary or not, our measures should be neutral in relation to the nature of treatment they intend to evaluate; otherwise, we might find treatments targeting the scales of measurement rather than the underlying pathological process (Fonagy, 2010).

The methodology we use to study the impact of our interventions also deserves scrutiny. Over the last couple of decades, the randomised controlled trial (RCT) has been held by many to be the gold standard in psychotherapy research. However, in his 2008 Harveian Oration at the Royal College of Physicians, Sir Michael Rawlins¹ (2008) cautioned against the over-valuation of RCTs in evidence-based medicine, focusing on whether the results of RCTs are generalisable. Indeed, the settings in which psychotherapy RCTs take place are quite different from the real clinical situation we are accustomed to as clinicians (La Greca et al., 2009; Weiss et al., 2009). Additionally, the treatment given in psychotherapy RCTs rarely fits clinical reality in terms of frequency of therapy, timing of administration, duration of therapy, inter-current treatments and the skills and commitment of the practitioners. There is therefore a real question about whether the assessment of benefit obtained from a trial can be applied to ordinary clinical settings.

Notwithstanding this cautionary preface, what does the extant evidence base tell us about our interventions?

The good news is that psychotherapy (in its generic sense) does work, with the average effect size of psychotherapy found to be 0.8 across probably over 1000 studies (Wampold, 2001, 2007). Effect size (ES) refers to the likelihood that a person treated with psychotherapy would be better off than a person in the control group if both were chosen at random (Cohen, 1962). It means that nearly three-quarters of patients who have psychotherapy are better off than those left to recover by themselves. Psychotherapy is mostly as effective as psychoactive medication, and there is evidence that additional benefit accrues from combining the two in some contexts (e.g. Cuijpers et al., 2009). Not surprisingly, improvement rates relate to severity and treatment duration (Kopta et al., 1999). On average, acute distress improves in three-quarters of cases within 25 sessions. But chronic disorders, defined in various ways, appear to require longer-term treatment.

For obvious reasons – not least economic ones - there is a strong interest in brief interventions not only from commissioners of mental health services but also in the private sector, where economic recessions and the exigencies of work make it hard for prospective patients to commit themselves to long-term interventions. Meta-analytic reviews have yielded powerful pre-post effects for psychodynamic psychotherapies for depression based on both RCTs and correlational studies (Abbass, 2007; Cuijpers, 2008; Knekt, 2008). There is evidence of comparable effectiveness with medication (Salminen, 2008) and its capacity to increase the effectiveness of antidepressant treatment (de Maat, 2008), although needing slightly longer to become clinically effective. It should be noted, however, that with sample sizes of 25 patients per arm, there was insufficient statistical power to be confident of detecting differences between treatments.

Comparison trials show that brief analytic interventions (also referred to as short-term psychodynamic psyc...