From the Editor
“Today, psychoanalysis has been marginalized and is struggling to survive in a hostile academic and clinical environment. This raises the question as to whether the paradigm is still relevant in psychiatric science and practice.”
This week, we consider the relevance of psychoanalysis.
Drawing from the May issue of The Canadian Journal of Psychiatry, we look at two papers.
In a Perspectives piece, Dr. Joel Paris argues that psychoanalysis is part our legacy – but not much more. In an Editorial, Dr. Paula Ravitz responds. She opens by writing: “My concern is that by unnecessarily pitting psychiatry against psychoanalysis, we may throw out the baby with the bathwater.”
It’s a great and important debate.
Paris on Therapy
“Is Psychoanalysis Still Relevant to Psychiatry?”
The Canadian Journal of Psychiatry, May 2017
“Psychoanalysis is a theory of psychopathology and a treatment for mental disorders. Fifty years ago, this paradigm had great influence on the teaching and practice of psychiatry. Today, psychoanalysis has been marginalized and is struggling to survive in a hostile academic and clinical environment. This raises the question as to whether the paradigm is still relevant in psychiatric science and practice.
“In a difficult climate for the theory and practice of psychoanalysis, several responses have emerged, either by attempting to bridge the gap with science or by redefining the field as lying outside of science. Thus, some analysts have supported revised paradigms, such as attachment theory, that are better supported by evidence. Others have taken the view that Freud’s ideas concerning the unconscious mind are compatible with modern neuroscience. Still others have moved in the opposite direction, arguing that it is sufficient to offer a coherent interpretation of psychological phenomena. This review will briefly examine all these attempts to revive psychoanalysis.”
So opens McGill’s Joel Paris in his paper. He predicts a “continued and lingering decline” for psychoanalysis. In a sweeping essay that draws heavily from the literature, he makes several points.
- Psychoanalysis has been undermined by a lack of scientific study. “The absence of solid and persuasive evidence for the theory may be the consequences of self-imposed isolation from the empirical sciences.” (He notes that attachment theory is the “notable exception.”)
- Even psychoanalysts, he writes, concede there is limited evidence. “Peter Fonagy, a psychoanalyst who is also a respected researcher, has acknowledged that ‘the evidence base for psychoanalytic therapy remains thin.’”
- Though there is evidence for time-limited dynamic psychotherapies, Dr. Paris argues that this isn’t generalizable to psychoanalysis. With psychoanalysis, “a few reports have attempted to examine” outcomes, but there have been serious limitations.
- Attempts to tap brain imaging to confirm analytic theories – such as using REM activity – have been “incompatible with empirical data.” Some, like Norman Doidge, have argued that the “brain can change itself” – but Doidge’s books are bestsellers, but “have had little impact in medicine.”
“Whatever its limitations, psychoanalysis left an important legacy to psychiatry. It taught a generation of psychiatrists how to understand life histories and to listen attentively to what patients say. In an era dominated by neuroscience, diagnostic checklists, and psychopharmacology, we need to find a way to retain psychotherapy, whose basic concepts can be traced back to the work of Freud, as part of psychiatry.”
“Contemporary Psychiatry, Psychoanalysis, and Psychotherapy”
The Canadian Journal of Psychiatry, May 2017
“In his Perspective, ‘Is Psychoanalysis Still Relevant to Psychiatry?’ Paris presents a critical perspective on psychoanalysis in the context of evidence-based care. Scientific discourse demands critical dialogue, and so in this editorial, I provide alternative perspectives on some of Paris’s arguments and further thoughts on psychoanalytic training, research, and treatment. My concern is that by unnecessarily pitting psychiatry against psychoanalysis, we may throw out the baby with the bathwater.”
So responds the University of Toronto’s Dr. Paula Ravitz to the Paris paper. She forwards several arguments.
- She notes that psychoanalytic thought is traced to various theories – and that a typical scientific consideration isn’t necessarily appropriate. “[C]urrent psychoanalytic thought is informed by theory of mind, feminist theory, queer theory, sociology, cognitive psychology, nonlinear dynamics, evolutionary biology, political science, anthropology, Buddhism, evolutionary psychology, and ethology. Many aspects of this rich interdisciplinary landscape of influences lie outside the domain of science and its standards of evidence, but not all.”
- That said, she observes “the strength of evidence” for different psychotherapies. “Canadian position papers and working group papers on psychotherapy published over the past 4 decades highlight that psychotherapy treatments are integral, core components of psychiatric practice.”
- And she taps the literature, “Although there are fewer controlled studies of psychoanalytic treatment, there is in fact evidence for the efficacy of both short- and long-term psychodynamic psychotherapy (LTPP). Leichsenring and Rabung’s systematic review of 23 studies conducted between 1984 and 2008 identified 11 prospective RCTs and 12 observational studies of >1000 patients receiving LTPP in which there was a large within group effect size of 0.96… for pre- to posttreatment overall outcomes, and for the 8 studies that included a comparison group, the overall between-group effect size was even larger at 1.8…”
“Psychotherapy treatments can effectively address suffering and enhance outcomes and the quality of care of mental illnesses across a spectrum of health care settings. As evidence-based practitioners and psychiatrists, we must use what is best for our patients and be trained in a broad range of effective treatments, including psychotherapies and psychoanalytic principles. Based on 40 years of outcome and process research, it is clear that psychotherapy treatments are helpful for patients with psychiatric disorders and therefore a critical component to be preserved in the training and practice of psychiatrists of the 21st century.”
A few thoughts:
- What a terrific exchange.
- Congratulations to the authors – and to The Canadian Journal of Psychiatry for publishing this debate. (And I would encourage readers to look at the papers themselves, since this summary is just that – a summary.)
- Though these two psychiatrists take different positions, there is clearly common ground. Note, for instance, that they both acknowledge the contribution of psychoanalysis to current care, including attachment theory. And both acknowledge the incredible importance of psychotherapy in terms of evidence-based care.
- A past Reading considered this topic, drawing on a clever Guardian essay, and then discussing an American Journal of Psychiatry paper that showed that CBT helped patients with bulimia achieve symptom relief faster than those treated with analysis – though the study did show that neither psychotherapy was particularly effective.
You can find the Reading here:
- In a publicly-funded system, there are larger questions. Does analysis justify its cost given the system’s limited resources? Is it problematic to think in these terms, with government officials then trying to pick winners and losers in treatment, potentially micro-managing patient care?
- These two selections, then, touch on a broader discussion – the relevance of psychoanalysis has implications for education, clinical practice, and health care financing. I’ll close the way I started: by noting that it’s a great and important debate.
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.