I have been talking with people in the community about what is “psychoanalysis.” The result? Many people no longer understand what is psychoanalysis – if they ever did understand it – or, even worse, have confused ideas about it. For example, as I seek referrals for two flexible fee control cases, I have been talking with people and the response has been “Why would anyone want to do psychoanalysis!?”  Others such as clinical psychologists, licensed practical counselors, or social workers (I am none of those) feel the need to apologize when using the word “psychoanalysis.” What to do about it?

Psychoanalysis can do things that no other Talk Therapy can accomplish in terms of restoring emotional well being, blasting through “stuckness,” and promoting a humanizing experience through empathy. Okay, okay – this is a short journal article, and more like ten sequential blog posts in one. I just had to get some things off my mind. The work goes on. Let the count-down begin –

10. Psychoanalysis takes a long time.

False. One of Freud’s shortest cases, that of Katarina (Freud 1893), was concluded in one day. Arguably, the shortest case that Freud conducted was of the composer Gustav Mahler. Freud says “I analyzed Mahler for an afternoon in the year 1912 (or 1913) in Leyden…” (See “Encounter at Lyden: Gustav Mahler Consults Sigmund Freud,” J. L. Kuehn, Psychoanalytic Review, 1965/66: 5-25.) His longest case lasted several years. There is room for individual variation here. Never was it truer that “your mileage may vary.” However, it is possible to obtain credible results with short term psychoanalytic psychotherapy in (say) forty sessions, two times a week over twenty weeks. Why twenty weeks? Because that is the arbitrary number that many insurance companies are authorizing for Cognitive Behavioral Therapy (CBT). In particular, the 20-session limit comes from “outcome research” performed in the 1990s. Some 90% of observable (and most superficial) changes occurred in the first 20 weeks of treatment. Specific symptoms, depending on the behavior, can be “disappeared” in two or three conversations, given the usual conditions and qualifications. However, what cannot be changed in a limited number sessions by any known treatment, notwithstanding mood altering medications (which do not even impact the mood of 50% of depressed patients), is the personality of the adult human being and its rich, complex tangle of tendencies, temptations, relational traumas, and traits. Still, there is reason to think that character development spontaneously occurs over time, even if with a glacial slowness, once self-protective tactics (“resistances”), obstacles, and “stuckness” is reduced, regardless of the method of treatment. What can be changed relatively more rapidly is a person’s relationship to her or his own character. However, all the usual disclaimers apply. That generally means telling the truth about how one relates to oneself, regardless of how confronting that may be, regardless of the risk that one will not look good in one’s own eyes or those of one’s inner circle. Sometimes that means stopping beating oneself up for not being the person someone else wanted one to be. Sometimes that means stopping fighting a losing battle (from the past) that is sapping one’s energy needed to succeed at life going forward. Sometimes that means acknowledging that suffering is “sticky” and one needs to give up the invented reasons for sticking with ineffective behavior and the resulting secondary gain, taking risks and moving out of one’s comfort zone.

9. Psychoanalysis is a movement; it is not evidence-based psychotherapy.

False – though it may be both. Psychoanalysis is a method of psychodynamic psychotherapy. The answer is direct. Growing numbers of studies are providing robust empirical data support that psychodynamic methods such as psychoanalysis are effectives forms of therapy. I ask the reader’s patience as we must necessarily spend some time on the complexities of evidence-based effectiveness. Evidence based interventions are distinct from evidence based outcomes. Further, evidence-based treatment as an outcome is distinct from evidence-based practice as an outcome. Given these distinctions, behavioral interventions are vulnerable. In the former the research looks at whether the actual intervention strategy or treatment paradigm is responsible for any change, specific change, or change in a hypothesized direction that are observed. Never was it truer that correlation is not causation. Evidence-based practice refers to a process of finding the optimal treatment protocol for a person, given the individual differences that exist for any single, actual person. For example, in a compelling meta study of the efficacy of psychotherapy assembled by Jonathan Shedler (University of Colorado School of Medicine) compelling documentation is provided that psychoanalysis is indeed evidence-based psychotherapy. In order to understand Shedler’s contribution, one needs to know the meaning of an “effect size.”  Shedler writes: ”An effect size of 1.0 means that the average treated patient is one standard deviation healthier on the normal distribution or bell curve than the average untreated patient. An effect size of 0.8 is considered a large effect in psychological and medical research, an effect size of 0.5 is considered a moderate effect, and an effect size of 0.2 is considered a small effect…” (Shedler 2010: 100). Shedler’s results must simply be seen to be believed: “A more recent review of short-term (average of 30.7 sessions) psychodynamic therapy for personality disorders included data from seven randomized controlled trials … The study assessed outcome at the longest follow-up period available (an average of 18.9 months posttreatment) and reported effect sizes of 0.91 for general symptom improvement (N = 7 studies) and 0.97 for improvement in interpersonal functioning (N = 4 studies)” (Shedler 2010: 101). These results need to be better known. When compared with the effect sizes of medications, the results reported by Shedler are embarrassing – to the medications: “An analysis of U.S. Food and Drug Administration (FDA) databases (published and unpublished studies) reported in the New England Journal of Medicine found effect sizes of 0.26 for fluoxetine (Prozac), 0.26 for sertraline (Zoloft), 0.24 for citalopram (Celexa), 0.31 for escitalopram (Lexapro), and 0.30 for duloxetine (Cymbalta). The overall mean effect size for antidepressant medications approved by the FDA between 1987 and 2004 was 0.31 …” (Shedler 2010: 100). Nor were Shedler’s results restricted to short term results: “A meta-analysis reported in the Journal of the American Medical Association … compared long- term psychodynamic therapy (= 1 year or 50 sessions) with shorter term therapies for the treatment of complex mental disorders (defined as multiple or chronic mental disorders, or personality disorders) and yielded an effect size of 1.8 for overall outcome. The pretreatment to posttreatment effect size was 1.03 for overall outcome, which increased to 1.25 at long-term follow-up (p = .01), an average of 23 months posttreatment” (Shedler 2010: 100). In fairness to psychoanalysis, it should be noted that the evidence of its effectiveness and its cost-based advantages is well documented. In addition, studies have shown that time and intensity does [can] make a significant difference. That is likewise the case with psychoanalysis. Longer treatment sessions and more intensive sessions (i.e., more times a week) also demonstrably increase the effectiveness of therapy. A final consideration for the cynics and skeptics. If a procedure or method cannot fail, then, by definition, it also cannot succeed. Psychoanalysis and dynamically oriented Talk Therapy do both (in addition to Shedler’s work cf. Goldberg 2012; Schlessinger and Robbins 1983; Orlinski 1978, 1986, 2005).[1]

8. Psychoanalysis does not address social issues such as gay rights, bullying, gender violence, etc.

False. One of the few things about which Freud never changed his mind was the essentially bisexual nature of the human being. Freud was explicit in asserting that he did not consider those attracted sexually to the same gender to be neurotic (i.e., expressing disguised symptoms of repression, pathology, or maladaptation). What Freud did encounter in his clinical practice were the constraining moral standards of his day against the expression of desire in various forms (both hetero- and homoerotic), resulting in suffering that was expressed symptomatically. Freud was appalled by the criminalization of homoerotic behavior in Great Britain (for which the celebrated playwright Oscar Wilde did jail time), and which is itself a measure of how different are the worlds in which Freud and we live. Freud says that the word “perversion” is in effect a technical term, not a devaluing one (though it has since become such) and that “healthy people” have variations in their sexual aims that “show how inappropriate it is to use the word ‘perversion’ as a form of reproach” (Freud 1905: 51). Any form of sexual activity that is not subordinate to reproductive genital sexuality to create children is “perverse,” according to the technical term. Do not quote this out of context but: “Get over it: We are all ‘perverts’ now.” While this is not a tutorial on Freud’s Three Essays on Sexuality (1905), the devil is in the technical detail. When Freud decomposed the sexual instinct into its components of impulse, variable object (male, female, fetish (shoe), animal), and aim (activity such as oral, anal, phallic), deviations from the standard of reproduction stopped being pathological, though they were still deviations from a norm. Freud himself stated that his method of treatment was committed to helping people to understand themselves and become comfortable with whom they felt themselves authentically to be, including those who sexual inclinations tended to go against the grain of the prevailing standards of his day. In that sense, Freud was about a century ahead of his time. Paradoxically it turns out that a “politically correct” stand on bisexuality is relatively easy for psychoanalysis to embrace, thanks to Freud’s position on bisexuality. More problematic are the many other social issues on which reasonable people may disagree or have nuanced positions that are not black or white. The failure of psychoanalysis to reach out and address psychological issues central to persons of color is an ongoing point of inadequate remediation (i.e., failure) (but see Young-Bruehl on Anatomies of Prejudice (1996) for a powerful contribution). Yet from another perspective, the challenge is that psychoanalysis is a method of treatment to eliminate or reduce emotional suffering, not a political movement. To the extent that psychoanalysis is committed to be patient-centered, its first impulse tends to ask the individual “Well, how do you feel about that?” Nothing wrong with that, but it can lead to a misunderstanding. In the case of domestic violence, for example, such an inquiry can seem inhumane, devaluing, blaming the victim (again) or even abusive. When people are suffering, being neutral, anonymous, and abstinent (abstaining from action/intervention) can look like being an uninvolved bystander while the victim and the perpetrator are locked in a life-and-death struggle (for the victim). Once again, psychoanalysis has not been its own best advocate in the face of complex, entangled social issues. It is small comfort that such is likewise the predicament of other professional organizations such atomic scientists (advocating against nuclear power/weapons), psychologists (bitterly disputing the merits of sending psychologists to the US Facility at Guantanamo Bay, Cuba), chemists and biologists debating the merits of genetically altered foods and crops, computer programmers taking a stand on privacy rights vis a vis government spying, etc. From a clinical perspective, the psychotherapist may usefully start out from a position of neutrality, at least rhetorically, to allow the patient to be self-expressed about her or his commitments to which the psychoanalyst is, in turn, committed to provide a gracious and generous listening. It is rather like the bumper-sticker prayer: to know when to be a bystander, when to intervene, when to lead, and how to tell the difference. What is required is not so much sensitivity training, empathy tends to make psychoanalysts empathic, but rather leadership training. Gone are the days of celebrity psychoanalysts – think of Erich Fromm’s The Art of Loving and its sales of 25 million copies or Bruno Bettelheim’s many controversial jeremiads or Erik Erikson’s work with adolescent identity in youth and crisis.

7. Psychoanalysis is no longer the therapy of choice given CBT (Cognitive Behavioral Therapy).

False. CBT was developed by two psychoanalysts, Albert Ellis and Aaron Beck, working separately and at different times. While the methods of CBT are significantly different than psychoanalysis, the relationship is a close one. There are ongoing debates about whether CBT is effective due to those aspects of empathic listening and optimal responsiveness that are the essence of psychoanalysis. The additional variations in technique are just that – variations on a theme that may work for individuals who require an active, directive, and confrontational approach such as that envisioned by CBT.

While this article is not a tutorial on CBT, some background will be useful. Albert Ellis published his initial work in the early 1960s, and he calls his version of CBT “rational emotive behavioral therapy” (Ellis 2001). It emphasizes unmasking and confronting the amazing cognitive and emotional gymnastics that people put themselves through. Ellis notes that people often make absolute and uncompromising demands on themselves that they would never ask of another person; people “should” all over themselves with absolute requirements for perfection; and people fail to distinguish between lack of commitment and temporary failure to live up to one’s commitments. Ellis writes humorously of “musterbation” – not masturbation, musterbation – whereby a person must reach a self-defined goal of financial wealth or fame or power and regards himself as worthless and of low value unless such conventional standards are satisfied. Ellis urges considering the rational reinterpretation that the person has just failed financially or at public relations but is still worthy of respect and dignity, pending another project to reach his goal. However, on a continuum between empathic listening and confrontational methods, Ellis’s approach is active, directive and towards the confrontational end of the spectrum. In short, CBT has an explanation of what is wrong with the patient and spends a strictly limited amount of time being understanding and empathic. One is presumed to be in therapy to get results quickly, and how to get results will be explained forthwith. Meanwhile, in parallel Aaron Beck (1976) developed his approach to CBT apparently without having major contact with Albert Ellis. Beck explicitly writes about how the psychoanalytic process of free association is good as far as it goes but misses something crucial.  It misses the “automatic thoughts” that are an essential part of the internal conversation in which a person judges and evaluates her- or himself as well as others, usually in a devaluing or distorting way. The internal monologue plays out barely beneath the threshold of awareness and creates all manner of mischief as “negative self talk,” “self handicapping rackets,” and “devaluing and distorting assessments of self and others” occurs. CBT aims at identifying, disclosing, interrupting, and disappearing such “automatic thoughts.” The response from the side of psychoanalysis is that Beck needed to be more attentive to the content of the free associations. All of these automatic ideas and more are available in the free associations, provided that one stops filtering them out. What distinguishes CBT from psychoanalysis remains the commitment on the part of CBT to active  and explanatory interventions that confront the patient, deemphasizing the preparatory work of understanding and empathy. In so many words, CBT urges its clients to “stop kidding yourself,” “get over it,” “get in action,” and stop talking down to oneself. Not bad advice if one can follow it. More to the point, the matter of lack of self-understanding and self-deception is complex and rarely yields to a frontal assault. It gets worse. If you read Beck carefully, the sessions are intended to be training in CBT. That is, the work with the trainer is to teach the patient/client how to do CBT so that he or she can go back into their lives and apply the therapeutic distinctions, reporting back periodically on the results. Most psychoanalysts are not as certain as CBT practitioners that they “get” what is really going on with the patient without dedicating themselves to an empathic listening in which the patient is empowered to be self-expressed about his or her issues without being judged or assessed. Survivors of hard-core CBT often endorse the assessment: Absent a warm empathic listening, psychotherapy is often indistinguishable from dental work – or CBT.

7.5 Psychoanalysis does not treat trauma.

False. Freud’s first eighteen patients experienced sexual boundary violations – in those days, euphemistically called “seductions” – amongst the definitive causes of their neuroses. Freud initially argued that a sexual trauma was the cause of hysteria, analogous to the tubercule bacillus being the cause of tuberculosis. A single condition contrary to fact cause: “If there had been no X (bacillus / sexual trauma), then there would have been no resulting Y (tuberculosis / hysteria); whereby the removal of the X, also causes the Y to disappear. However, Freud subsequently had to give up the account in the face of compelling evidence that in some cases at least the overwhelming anxiety (“trauma”) was imaginary, fictional, psychic and a part of standard development of the moral conscience (i.e., superego). The debate goes on. The decisive engagement with trauma as a source of neurosis occurred during and after World War I, which invented new horrors to civilians and soldiers all around. Individual soldiers were over come with what was called “shell shock,” an early version of World War II’s “battle fatigue” and today’s post traumatic stress disorder (PTSD). The treatment of choice at the time on the part of army doctors was to assume that the soldier was malingering and to threaten (and apply) punishments to enforce conformity to duty. A psychoanalytically inspired Army psychiatrist, Ernest Simmel, found that talking to the soldier using psychoanalytic methods was effective in returning the soldier to duty with integrity and restored well-being. A conference was held in September 1918 with Freud and key psychoanalysts such as Ernest Jones, Karl Abraham, and Sándor Ferenczi at which government representatives from the German and Austrian governments were present. An ambitious project was envisioned at which Clinics and Hospitals would be set up using psychoanalytic methods for treating war neuroses. There was a real prospect that psychoanalysis would “break out” to the general public. The collapse of these governments and the post-WW I political and economic chaos thwarted this vision. However, Freud went on to publish Beyond the Pleasure Principle (1921) in which the mastery of trauma through the repetition compulsion was on the critical path to dealing with aggression and overcoming neurotic suffering.  Given that our community is dealing with the return of soldiers from two wars, psychoanalytic methods are more important than they have ever been before.

6. Psychoanalysis has not progressed since Freud.

False. Progress in psychoanalysis has occurred in at least three waves since its invention in 1900 as a method of making sense out of symptoms lacking a somatic cause, dreams, and cultural artifacts such as artworks. After calling attention to the interest of young children in bodily functions and immature forms of sexuality, early colleagues of Freud such as Melanie Klein and Freud’s own daughter, Anna Freud, engaged in the innovation of actually talking to children and observing infants to learn how they related to their own unfolding developmental challenges of emotions, language, and cognition.  Educators, including the renowned psychoanalyst Erik Erikson, applied the lessons of introspection to teenagers and young adults struggling with issues of ego identity versus role confusion in National Award Winning works such as Gandhi’s Truth and Young Man Luther. D. W. Winnicott, a pediatrician, was for a long time a voice crying in the wilderness until his colleagues realized that his gentle and charismatic empathy made it possible to expand psychoanalysis to treat and restore to well being seriously distressed individuals who hid the possibilities of their authentic humanness behind a façade of a false self designed to conform to the impingements of mal-attuned parents and other authority figures. The work of Heinz Kohut on empathy and introspection has reoriented psychoanalysis towards the challenges of overcoming reactions to devaluing labels and assessments of an all-to-rigid approach to transforming human suffering. Arnold Goldberg extended Kohut’s work on narcissistic personality disorders to narcissistic behavior disorders with powerful and humanizing results. Robert Stolorow extended Kohut’s distinction of selfobject to an intersubjective context of ongoing empathic attunement (Stolorow et al. 1992). This list is not complete. There have been many other innovations, and I have already unwittingly slighted many valued colleagues by leaving out the names of many dedicated clinicians and researchers who have made a profound and positive difference for their patients and clients.

This is the good news. The less good news is that in the course of over a century, has psychoanalysis has made wrong turns, hit speed bumps, and suffered setbacks, at times seeming to be its own worst enemy. For example, in the hey-day of atomic physics and positivistic science, the then-leading ego psychologist, Heinz Hartmann, went head-to-head with philosopher of science Ernest Nagel in a public intellectual debate, attempting to prove that psychoanalysis had a scientific basis similar to the molecular theory of gases (Agosta 1976). Hartmann failed – spectacularly. He would have been wiser to emphasize the commitment of psychoanalysis to self-knowledge and self-understanding with a view to exploring the hidden motives that allow people unwittingly to misunderstand themselves, thereby self-defeatingly and self-deceivingly prolonging their own suffering. Instead of trying to wrestle secrets from nature as classical physics and brain science of today, the commitment of psychoanalysis is to discover the secrets about oneself and how one fools oneself about one’s own motives and desires – and how one (and one’s community) suffers as a result. Unlike human beings, nature is not capable of a pathogenic secret. Human beings unwittingly keep secrets from themselves – and then are amazed when their lives do not work. To say that people regularly engage in self-deception, albeit unwittingly, is confrontational. It seems like hard medicine. Expanded empathy is required. The methods that human beings use to protect themselves rely on finessing the boundary between wishes and what is so in the community. People have self-protective strategies – often called “defenses” – that occur not only because of external dangers, but also because the mind (“psyche”) is overwhelmed by painful deformities that occur during development or as a result of diverse traumas or interpersonal isolation.  Nevertheless, lack of self-understanding has a crucial role to play in keeping defenses in place and paradoxically staying within the comfort zone of familiar emotional suffering instead of asking the tough questions and taking prudent risks. The conversation that discloses what is hidden from oneself is no ordinary one. When undertaken in the context of a humane, empathic listening, it does not have to be painful or re-traumatizing. From the perspective of that conversation, psychoanalysis delivers something that no other disciplines is able to provide quite as well, self-knowledge.

5. Psychoanalysis is expensive.

It depends. One thing is definite. Doing nothing is expensive, too. The most expensive approach is doing nothing about personal, emotional suffering – it can cost a person a lifetime of satisfaction and fulfillment, do almost incalculable harm to entire families, and damage whole communities through violence, substance abuse, and diverse anti-social behavior. As Freud wrote in his Recommendations for Physicians Beginning Psychoanalysis: “Nothing in life is so expensive as illness and foolishness.” Alas, in many ways, the market for psychotherapy services is dominated neither by the influence of the buyers (patients) or the sellers (e.g., psychoanalysts) but by the power of the gate-keepers, the insurance companies. How to put it delicately? In the current (Q4 2013) market, power has shifted to the insurance companies, dominated by the power of the gate-keepers, the insurance companies, whose inadequate reimbursements, second guessing of treatment methods, and opportunistic behavior has squeezed both patients and providers. Thus, for those patients and providers who are willing to work together, there are mutually beneficial deals to be made. If a person has limited financial resources and is willing voluntarily to disclose the situation to a prospective psychoanalyst, then there are many psychoanalysts who are prepared to be flexible about pricing. From the point of view of the buyer of psychotherapy services, it can seem unfair both to be in a personal crisis and to have to negotiate about fees. Alas, welcome to the new world of healthcare where the consumer is responsible for his or her own health and well being, regardless of ability to pay. Unlike during the first-wave of psychoanalysis and dynamic talk therapy as recently as the early 1990s, there are few professional who have or need to maintain a waiting list for prospective clients and patients. Wouldn’t it be nice? For those consumers able to pay something out of pocket and dispense with the ongoing interference of insurers, many psychotherapists are willing to be flexible. Other options for consumers include identifying a psychoanalyst who is building her or his practice and is willing to flexible about pricing or to seek out a clinic affiliated with a psychoanalytic institute where flexible fee services are available. In such situations, psychoanalysis can be compellingly affordable. The guidance is to be an informed consumer, and make a case for and ask for what one needs, emphasizing personal style, scheduling, and cost.

4. Psychoanalysis is not the therapy of choice, given psychiatric, psychotropic medications (e.g., Prozac).

False. In 1993 someone named Peter Kramer published a book entitled Listening to Prozac. This book knocked the knees out from under all forms of Talk Therapy, without exception, and, as the jewel in the crown, psychoanalysis perhaps had more at stake and further to fall than most. Kramer’s promises of “personality brightening” in a pill were abroad in the land, even if the ultimate outcome was disappointing. It turned out to be worse than disappointing – it turned out to be veritable deal with the devil. And, as with all deals with the devil, the fine print was not to be neglected even though it was neglected. Some forms of unipolar depression were temporarily shifted and interrupted by fluoxetine (Prozac), but the effects on bipolar depression were profoundly unpredictable or even negative in some cases. The complex differential diagnoses between unipolar and bipolar became a matter of controversy even among accomplished psychopharmacologists, the latter being all-too-infrequently consulted by the family doctors and front line M.D.s prescribing the now in-demand SSRIs (selective serotonin reuptake inhibitors). Some “misdiagnosed” patients “went up” and incurred suicidal ideation and behavior with tragic results. It gets worse. Since then, growing evidence has been published that SSRIs increase rapid cycling of a disorder that might otherwise have a significant chance of remitting spontaneously or under the influence of traditional Talk Therapy. This research is complex, but compelling (Ronalds 1997; Weel-Baumgarten; Patten 2004; Whitaker 2010). The growing concern about “rapid cycling” – periodic recurrence and shifting in the direction of becoming chronic – has spread, along with the pharmacological “revolution,” from bipolar to anti-anxiety, attention deficit, and even so-called second generation anti-psychotic medications.

Regarding second generation anti-psychotics, which are now sometimes added to anti-depressants as enhancers or modifiers, the news is even more sobering. Stephen Stahl is one of America’s most published psycho-pharmacologists and he has been occasionally criticized for his actual or imagined services to Big Pharma. Therefore, it is all the more compelling when Stahl writes:

“Atypical [so-called second generation] antipsychotics have been on the market for over a decade, and only now [2008] is it becoming clear that some of these agents are associated with significant cardiometabolic risk…and with pharmacological actions that may mediate this cardiometabolic risk…At first, weight gain and obesity were clearly linked to atypical antipsychotics, but more recently, increased risk for dyslipidemia, diabetes, accelerated cardiovascular disease, and premature death have been linked to certain drugs in this class as well” (Stahl 2008: 383)

“Premature death” indeed. Such statements are bound to give pause to any overzealous tendency to medicate. Most talk therapists, including psychoanalysts, will take a hard look at the cost/benefit calculation and hesitate in the face of the use of medications, all other things being equal. Why? As soon as the going gets tough and the patient faces uncomfortable truths about him- or herself, the temptation to escape into a fog of medication-induced mood alteration looms large. However, in the face of a constant drum beat of prospective patients requesting a way to feel better right away – even though the medications demonstrably do not work that way – and driven by now legal and – how to put it delicately? – self-serving advertisements from pharmaceutical manufacturers, even savvy practitioners, who ought to know better, can feel pressured into writing scripts (when they are M.D.s) or making referrals. The take-away here is that the process of conversation between two human beings, one of them a psychoanalyst, can be as powerful an agent for reducing emotional suffering and creating possibility, and will probably have fewer medical side effects than any psychotropic medication. In a sense, the “method of choice” is what the prospective patient requests as she or he comes in the door. In another sense, the prospective patient needs to be well informed in order to make a choice and that may include a trial psychoanalysis. In any case, any medication has a cost-benefit and risk profile that requires careful consultation between patient and medical doctor.

NOTE: I would be most obliged if some reader would point me to the exact reference to the APA study of 1999? (not sure of the year) that provided data indicating that the least recidivism to second and third depressive episodes occurred among individuals who used only psychotherapy (rather than therapy and medications, including SSRIs) to resolve the depressive episode. (See also Kirsch, I. & Sapirstein, G. (1999) Listening to Prozac but hearing placebo: a meta-analysis of antidepressant medications. In How Expectancies Shape Experience (ed. I. Kirsch), pp. 303-320. American Psychological Association.)

3. The understanding of psychoanalysis amongst the general public is high.

Guffaw. [False.]  The general public thinks that Freud was a cocaine addict and child molester who reduced human beings to sex and aggression. Such opinions are inaccurate, misleading, and false. Though often explicitly dismissed, Freud’s basic ideas have infiltrated their way into the fabric of society and spread so widely in American culture that they are common place wisdom and taken for granted as part of the background of our thinking. Consider several examples: People commonly speak of a “Freudian slip,” which means that the individual discloses a hidden motive, unwelcome opinion, or ambivalent feeling by unwittingly expressing an inconvenient fact or opinion. Furthermore: Trauma profoundly affects a person’s ability to function; trauma can “live on” in the form of nightmares, symptoms, and anxiety, inhibitions, cognitive blunting, impulse control issues and chronic repetition, unless worked through and integrated into a person’s consciousness awareness. The way we are treated by our caretakers as children has a strong influence on our adult lives. The sexual and aggressive mistreatment of children in boundary violations does occur and has negative consequences for the well being of the person into whom that child grows, requiring intervention and treatment to promote healing and recovery. People have complex motives, are ambivalent and of “two minds” about their relationships with family and friends. People tend to criticize others for things they see in themselves (but do not wish to recognize in themselves). Therapists must respect the boundaries between patient and therapist and it is unconditionally bad to use the therapeutic relationship to gain sexual or other favors. All of these ideas and many others originated with Freud and his early followers (who did not always follow Freud’s guidance). In that sense, it is shocking – shocking, I tell you – to consider that every psychotherapist is (gasp) a follower of Freud. We are all Freudians now. Yet methods, paradigms, and techniques has changed substantially since Freud’s time so that hardly any therapist is a pure Freudian in the narrow sense without condition or qualification. (See also Shedler (2006) for a nice overview.) Yet the challenge remains. For most people, above all, it is imperative to be allowed to remain in one’s comfort zone. However, psychoanalysis is precisely the discipline that says “Don’t get too comfortable!”

2. The level of teaching about psychoanalysis at liberal arts colleges and large state universities is high

Double guffaw. [False.] One does not know whether to laugh or cry as the meaning is “lost in translation.”When given a pre-test about their preconceptions about psychoanalysis, undergraduates produce some shockingly inaccurate statements (see above about cocaine, child abuse, etc. (Shedler 2006)). It is a caricature of psychoanalysis at the level of a New Yorker cartoon, that psychoanalysis reduces human beings to sex and aggression. The issue may be deeper than the understandable lack of personal psychoanalysis on the part of most college teachers. From the very beginning, the cynics pointed out that Americans would accept psychoanalysis on the condition that they were allowed to mistranslate it and water it down so that it became impersonal. Where Freud wrote in a common everyday language, using the word “I” to refer to the person and “it” to refer to impersonal instinctive forces, Freud’s translators adopted a Latin-based idiom, writing about “the ego” and “the id.” Where Freud wrote about investing sexual desire in a loved one and slips of the tongue, the translators invented quasi-medical terms such as “cathexis” for investment of affection and “parapraxis” for slips. Meanwhile, the hard-earned authority of the medical doctor who performed a couple of tests and then told you what was wrong with you and what antibiotic to take to kill the microbe and get over the illness tends to skew what is otherwise a conversation for possibilities of personal satisfaction and transformation. The emphasis on empathy in psychoanalytically-oriented psychotherapy has cleared the way to transforming suffering into a source of creativity, humor, wisdom, and an appreciation of humanity’s finitude. This is not to say that humans are not sexual and aggressive – review the news reports. They are. Yet psychoanalysis provides a method of finding meaning amidst the absurdity of the sexual and aggressive reactions to stress, scarcity, and interpersonal breakdowns, transforming breakdowns into breakthrough that provide possibilities for new ways of productivity and human relatedness.

1. The approach of psychoanalysis to proposed interpretations of the patient’s issue is “Heads I win; tails, you lose” – if the patient agrees, then that is agreement (and the psychoanalyst is right). If the patient disagrees, then that is resistance (and the psychoanalyst is right).

False. Even if the patient agrees that is not agreement. It could be conforming and agreeing with authority. It is only if additional relevant personal material is expressed that aligns with the interpretation that it is considered to be a confirmation (“yes”). Oftentimes a “no” means that the interpretation is incomplete or something significant is missing. First, if a practice or method such as psychoanalysis cannot fail, then can it really succeed?  Of course not. If a practice such as psychoanalysis can fail and confront and integrate its failures, then it can also succeed and flourish. Such is the point of the celebrated philosopher of science, Karl Popper, in his exploration of positive science in Conjectures and Refutations (1963). That continues to be and indeed is the program going forward. Psychoanalysis does both – fails and succeeds. But we look forward to hearing more about its strengths and weaknesses from psychoanalysts themselves rather than from psychopharmcologists, behaviorists, etc. whose expertise lies elsewhere. For example, Arnold Goldberg advances the view in his The Analysis of Failure (2011) that the openness of science to self-correction is a productive model for psychoanalysis.  To those who are still skeptical of hermeneutics, narrative, and deconstruction, Goldberg points out that the natural sciences have advanced most dramatically by formulating and disproving hypotheses. Scientific knowledge advances by engaging and overcoming failures. So does interpretation. While psychoanalysis is not a natural science in the narrow sense, its method is parallel to one in that psychoanalysis progresses through the engaging and overcoming of failures and misunderstandings. Goldberg suggests that within the interpretive/hermeneutic paradigm, psychoanalysts, who pride themselves on the courageous exploration of patients’ self-deceptions, blind spots, and self-defeating behavior, might well also engage in self-examination. “Physician heal thyself!”  is the subtext here. The professional ambivalence about taking a dose of one’s own medicine upfront in analyzing failed cases of psychoanalysis is a central focus in Goldberg’s work on psychoanalytic failure. Such an inquiry into failure ought to be undertaken in related areas of psychiatry, psychopharmacology, cognitive behavioral therapy (CBT), social work, clinical psychology, and so on. When an analytic case fails – indeed, determining what constitutes failure is a substantial part of the work – Goldberg looks for the sources of the selfobject rupture, where “selfobject” includes the representation of the other within the self. Goldberg’s key message is to avoid finger-pointing while still taking responsibility. A series of questions are bound to occur to investigators to locate responsibility: What’s wrong with the patient? What’s wrong with the therapist? What’s wrong with the treatment method(s)? What’s wrong!? In engaging these questions Goldberg argues that they must be put in perspective, put in the context of the broader question of absence. That is, what is missing in the experience of failure, the presence of which would have made a difference? Goldberg’s answer will often, but not exclusively, turn in the direction of a Kohut-inspired interpretation of sustained empathy. This is just an example of how unfair it is to say that “Heads I win, tails you lose” is the approach to interpretation in psychoanalysis. Psychoanalysis makes a difference in both easy and hard cases, deploying methods, interrelational technologies, and paradigm shifting tools, where no other treatment method is able to get traction.

References

Lou Agosta. (1976).”Intersecting languages in psychoanalysis and philosophy.” International Journal of Psychoanalytic Psychotherapy, Vol. 5, 1976: 507-34.

Aaron T. Beck. (1976). Cognitive Therapy and the Emotional Disorders. New York: Meridian / Penguin, 1979.

Albert Ellis. (2001). Overcoming Destructive Beliefs, Feelings, and Behaviors. New York: Prometheus Books.

G. Fava, “Do antidepressant and antianxiety drugs increase chronicity in affective disorders?” Psychotherapy and Psychosomatics 61 (1994): 125-31.

S. Freud. (1893). “Katarina (Case 4), Case Histories” from Studies on Hysteria. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume II (1893-1895): Studies on Hysteria, 135-181.

S. Freud. (1905). Three Essays on the Theory of Sexuality, tr. J. Strachey. New York: Avon / Discus Books, 1962.

Arnold Goldberg. (2012). The Analysis of Failure: An Investigation of Failed Cases in Psychoanalysis and Psychotherapy. New York: Taylor and Francis / Routledge.

D. Goldberg, “The effect of detection and treatment on the outcome of major depression in primary care,” British Journal of General Practice 48 (1998): 1840-44.

Lou Marinoff. (2000). Plato Not Prozac! New York: Quill Publishing, 2000.

S. Patten. (2004). “The impact of antidepressant treatment on population health,” Population Health Metrics 2 (2004): 9.

C. Ronalds. (1997).  “Outcome of anxiety and depressive disorders in primary case,: British Journal of Psychiatry 171 (1997): 427-33.

Nathan Schlessinger & Fred Robbins. (1983). A Developmental View of the Psychoanalytic Process: Follow-up Studies and Their Consequences. New York: International Universities Press.

Jonathan Shedler. (2010). “The efficacy of psychodynamic psychotherapy,” American Psychologist, February-March, Vol. 65, No. 2, 98–109 DOI: 10.1037/a0018378

Jonathan Shedler. (2006). “An Introduction to Contemporary Psychodynamic Therapy). “That was then. This is now.” http://www.psychsystems.net/Publications/Shedler/Shedler%20(2006)%20That%20was%20then,%20this%20is%20now%20R7.pdf [checked 2013-11-25]

E. Weel-Baumgarten. (2000). “Treatment of depression related to recurrence,” Journal of Clinical Pharmacy and Therapeutics 25 (2000): 61-66.

Stephen M. Stahl. (2008). Stahl’s Essential Pharmacology: Neuroscientific Basis and practical Applications, 3^rd edition. Cambridge, UK: Cambridge University Press.

Robert Stolorow and George Atwood. (1992). Contexts of Being: The Intersubjective Foundations of Psychological Life. New York: The Analytic Press (Taylor and Franics).

Robert Whitaker. (2010). Anatomy of an Epidemic. Broadway Paperbacks / Random House.

Elisabeth Young-Bruehl. (1996). The Anatomy of Prejudices. Cambridge, MA: Harvard University Press.

Footnotes:

[1] Arnold Goldberg. (2012). The Analysis of Failure: An Investigation of Failed Cases in Psychoanalysis and Psychotherapy. New York: Taylor and Francis / Routledge. Nathan Schlessinger & Fred Robbins. (1983). A Developmental View of the Psychoanalytic Process: Follow-up Studies and Their Consequences. New York: International Universities Press.  David E. Orlinsky & Howard K. I. (1978). “The relation of process to outcome in psychotherapy.” In S Garfield & A Bergin (eds) Handbook of Psychotherapy and Behavior Change, 2nd ed. New York: Wiley. David E. Orlinsky & Howard K. I. (1986) “Process and outcome in psychotherapy.” In S Garfield, A Bergin (Eds) Handbook of Psychotherapy and Behavior Change, 3rd ed. New York: Wiley. David E. Orlinsky & Rønnestad M. H. (2005) How Psychotherapists Develop: A study of Therapeutic Work and Professional Growth. Washington, DC: American Psychological Association.

© Lou Agosta, Ph.D. and the Chicago Empathy Project (LAgosta@UChicago.edu)

Categories: empathic understanding, Empathy, empathy consulting, empathy trends

Tags: CBT, Empathy, Psychoanalysis, psychotherapy