Head to Head: Does psychoanalysis have a valuable place in modern mental health services?

Head to Head: Does psychoanalysis have a valuable place in modern mental health services?

Source: http://internationalpsychoanalysis.net/wp-content/uploads/2012/03/SpielmanIndefenceofpsychoanalysisYes-No.pdf

BMJ 2012; 344 doi: 10.1136/bmj.e1211 (Published 20 February 2012) Cite this as: BMJ 2012;344:e1211

1. Peter Fonagy, Freud memorial professor and head of research 1, chief executive 2,
2. Alessandra Lemma, unit director3, clinical director4

Author Affiliations
1. p.fonagy@ucl.ac.uk

Peter Fonagy and Alessandra Lemma say that the psychoanalytical approach can provide a useful and unique
contribution to modern healthcare, but Paul Salkovskis and Lewis Wolpert argue that it may have no place
there at all (doi:10.1136/bmj.e1188)

Psychoanalysis is under greater attack than ever before. An
unprecedented decommissioning of psychoanalytic
services has taken place across the United Kingdom’s National Health Service (for example, Forest House NHS
Psychotherapy Clinic), justified by cost savings. What are the reasons for this attack and what can be said in
psychoanalysis’s defence?

It has been claimed, perhaps fairly, that psychoanalysis and psychodynamic psychotherapies have failed to
promote a culture of systematic evaluation and that the outcomes are difficult to measure and demonstrate.
Relative to the number of studies on the effectiveness of cognitive behavioural therapy, few adequate studies are
available of psychodynamic therapy outcomes. A growing body of studies, however, report that psychodynamic
therapy is effective in the treatment of both mild and complex mental health problems. For example, a metaanalysis found substantial effect sizes in randomised controlled trials of long term psychodynamic psychotherapy, larger than those for short term therapies.1 Positive correlations were also seen between outcome and duration
or dosage of therapy. Another meta-analysis found that psychotherapy in addition to antidepressants significantly
reduced depressive symptoms compared with antidepressants alone.2 A third meta-analysis found that short
term psychodynamic psychotherapy may be more effective than other therapies for somatic disorders.3 So
evidence is on its way.

Convergent support for psychoanalytic approaches comes from 20 studies of brain function changes after a range of psychotherapeutic treatments, including psychodynamic ones, for several mental disorders.4 Brain changes that have been shown include a substantial increase in 5-HT1A receptor density in patients with major depressive disorder after psychodynamic therapy—this was not the case in patients who received fluoxetine5—and normalisation of neuronal activity in patients with somatoform disorders.6 Ultimately these investigations will enable us to better understand the therapeutic mechanisms of a range of approaches and provide badly needed improvements in our treatments of complex disorders. The psychoanalytic approach makes three valuable and unique contributions to a modern healthcare economy. First, in their applied form, psychoanalytic ideas can support mental health staff to provide high quality services despite the interpersonal pressures to which they are inevitably exposed when working with disturbed and disturbing patients. Psychoanalytic understanding helps us to respond in humane ways when anxiety and stress threaten our ability to contemplate behaviour in terms of underlying mental states. The framework psychoanalysis provides for understanding why things go wrong in therapeutic relationships draws on a well-developed theory of interactional process.7 There are few viable alternative models for how a disturbed individual or community can
affect the thinking and behaviour of those engaged with them.

Secondly, there are increasingly strong indications that adult mental health problems are developmental in nature; three quarters can be traced back to mental health difficulties in childhood, and 50% arise before age 14 years.8 The psychoanalytic model is unique in proposing a developmental theory (of attachment relationships)
that is now firmly supported by evidence.9 It therefore allows us to understand the relationship between early experience, genetic inheritance, and adult psychopathology. This developmental framework emphasises early intervention and has been critical in shaping positive mental health policy, including the UK government’s “No Health Without Mental Health” strategy.10 Acknowledging the
developmental, relational foundations of mental health also has important implications for prevention.

Thirdly, psychoanalytical ideas continue to provide the foundations for a wide range of applied interventions. Research and clinical observation show that other modalities— particularly cognitive behavioural therapy—have made use of theoretical and clinical features of the psychoanalytic approach and incorporated these into their techniques. This may well enhance the overall effectiveness of these modalities; for example, some evidence suggests that the good outcomes achieved by other therapies correlate with the extent to which those therapies use psychodynamic techniques.11

Research clearly shows that there is no one size fits all approach to the treatment of mental health problems; irrespective of brand, psychotherapy only substantially helps around 50% of referred patients who complete treatment12 and medication fares no better.13 Rationally designed services should therefore provide a range of
approaches for which some evidence of effectiveness exists, and should continue to broaden the research base to ensure monitoring and improvement of the effectiveness of these services. More
comprehensively, perhaps, than any other theory of the mind, psychoanalysis points to key psychological phenomena and processes (such
as the limitations of consciousness, defences, resistance to treatment, transference and countertransference). These have to be integrated into our understanding of clinical work if adequate and effective psychological treatment is to be offered. If psychoanalysis is thrown out, these aspects of the mind will have to be
rediscovered—just like Greco-Roman culture was rediscovered after the dark ages. Notes Cite this as: BMJ 2012;344:e1211

Footnotes
• Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have
an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
• Does psychoanalysis have a valuable place in modern mental health services? is
the subject of a Maudsley debate at the Institute of Psychiatry, King’s College London on 7 March 2012 (www.iop.kcl.ac.uk/events/?id=1106).
• Provenance and peer review: Commissioned, not externally peer reviewed.

References
1. տ Leichsenring F, Rabung S. Long-term psychodynamic psychotherapy in complex mental disorders:
update of a meta-analysis. Br J Psychiatry 2011;199:15-22.
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2. տ Jakobsen JC, Hansen JL, Simonsen E, Gluud C. The effect of adding psychodynamic therapy to
antidepressants in patients with major depressive disorder. A systematic review of randomized
clinical trials with meta-analyses and trial sequential analyses. J Affect Disord2011, published online
16 Apr.
3. տ Abbass A, Kisely S, Kroenke K. Short-term psychodynamic psychotherapy for somatic disorders.
Systematic review and meta-analysis of clinical trials. Psychother Psychosom 2009;78:265-74.
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4. տ Karlsson H. How psychotherapy changes the brain. Psychiat Times 2011;28:8.
5. տ Karlsson H, Hirvonen J, Kajander J, Markkula J, Rasi-Hakala H, Salminen JK, et al. Research letter:
psychotherapy increases brain serotonin 5-HT1A receptors in patients with major depressive
disorder. Psychol Med 2010;40:523-8.
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6. տ De Greck M, Scheidt L, Bölter AF, Frommer J, Ulrich C, Stockum E, et al. Multimodal
psychodynamic psychotherapy induces normalization of reward related activity in somatoform
disorder. World J Biol Psychiatry 2011 Jun;12:296-308.
7. տ Lemma A, Target M, Fonagy P. Dynamic interpersonal therapy: a clinician’s guide. Oxford University
Press, 2011.
8. տ Kim-Cohen J, Caspi A, Moffitt TE, Harrington H-L, Milne BJPR. Prior juvenile diagnoses in adults
with mental disorder: developmental follow-back of a prospective longitudinal cohort. Arch Gen
Psychiatry 2003;60:709-17.
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9. տ Cassidy J, Shaver PR, eds. Handbook of attachment: theory, research, and clinical applications. 2nd
ed. Guilford, 2008.
10. տ Department of Health. No health without mental health: a cross-government mental health outcomes
strategy for people of all ages. 2011.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_12376 11. տ Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychologist 2010;65:98-109.
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12. տ Fonagy P. The changing shape of clinical practice: a comprehensive narrative review.
Psychoanalytic Psychother2010;24:22-43.

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13. տ Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al.
Antidepressant drug effects and depression severity: a patient-level meta-analysis.
JAMA2010;303:47-53.
FREE Full Text

Head to Head
Does psychoanalysis have a valuable place in modern mental health services? No BMJ 2012; 344 doi: 10.1136/bmj.e1188 (Published 20 February 2012) Cite this as: BMJ 2012;344:e1188

1. Paul Salkovskis, professor of clinical psychology and applied science1, 2. Lewis Wolpert, emeritus professor of biology as applied to medicine2

Author Affiliations
1. P.M.Salkovskis@bath.ac.uk

Peter Fonagy and Alessandra Lemma say that the psychoanalytical approach can provide a useful and unique
contribution to modern healthcare (doi:10.1136/bmj.e1211), but Paul Salkovskis and Lewis Wolpert argue that
it may have no place there at all

Psychoanalysis is of historical value only and, at best, has no place in modern mental health services. Not only is
there no evidence base for the treatment, but there is no empirical grounding for the key constructs underpinning
it. In addition, we suggest that the theory and practice of
psychoanalysis are inimical to modern mental health
services and so are, at worst, counterproductive and perverse in that context.

We do not doubt the historical significance of psychoanalysis, psychoanalytic theory, and its founding father,
Sigmund Freud. The theoretical concept of the unconscious provided the foundations of current cognitive
sciences. Modern evidence based and empirically grounded psychological therapies,1 including cognitive
behaviour therapy, were initially developed by clinicians who were trained in psychoanalytic approaches but
found the approach wanting.2 Even the small number of evidence based psychodynamic therapies are very far
removed from the basic dogmas of psychoanalysis and show little or no evidence of their provenance; neither the
analyst’s couch nor free association is in evidence. As regards evidence, they are often ineffective, even relative
to being on a waiting list.3Clearly, true paradigm shifts have occurred in terms of the understanding of human psychology and of the ways
in which people experiencing psychological problems and distress can be helped. Freud himself deserves credit
for establishing psychoanalysis as a new paradigm over a century ago. There is, however, an inevitability in the
subsequent shift away from psychoanalysis, which began 50 years ago and which was de facto completed in the
1980s. Paradigm shifts are a form of accelerated intellectual evolution, where the explanatory and heuristic
power of a particular theory are supplanted by another that better explains and predicts the key phenomena
under investigation. Sometimes a supplanted idea is kept alive in some form; there is something charming and at
times amusing about the continued existence of a flat earth society or the psychoanalytic approach to literary
criticism. However, we propose that it is no longer defensible to continue ideas whose time has come and gone
and which have been succeeded by more appropriate ones in an area as important as healthcare. It would not be
tolerated in cardiology or oncology; why should it be in mental health? In evolutionary terms, psychoanalysis can
be regarded as a metaphorical appendix; vestigial and unfortunately of no continuing value.

Psychoanalysis rejected Freud’s original concept of psychoanalytic science.4 We suggest that psychoanalysis
has become a pseudoscience because its claims are neither testable nor refutable. Attempts to identify evidence
for constructs such as the id, ego, and superego and concepts such as the oedipal complex have sadly failed.
Psychoanalysis has had its day, and more. It dominated psychological approaches for well over half a century,
during which time it essentially stagnated, becoming conservative and authoritarian, depending on flawed
wisdom of tribal leaders. As a movement, it greeted the development of the upstart behaviour therapy and later
cognitive therapy by actively resisting, with passion and fury, the notion of outcome evaluation, and opposed
what it regarded as the dangerous obscenity of symptom focused approaches. It still does.5

Psychoanalysis is quite different from psychiatry because it makes no attempt to diagnose a patient’s condition,
and so does not recognise problems such as schizophrenia or others with a genetic cause. The patient does not
have a defined illness and so no attempt is made to find a cure. This also means that the true psychoanalyst will
resist medication for the patient. The treatment is also expensive because the patient typically attends sessions
several times a week, usually over several years. The average duration of psychoanalytic treatment in the United
States is estimated to be over five years.

Our opponents in this debate might choose to argue the usefulness of psychodynamic approaches, such as
mentalisation and interpersonal therapy, given their associated research findings. They will find no argument from
us. Neither, however, will they find a couch in the consulting rooms of those who practise such approaches—
these methods are successors to psychoanalysis, rather than a continuation. Is there value in some input from psychoanalysis in mental health? There are at least three reasons for a clear
“no”. Firstly, historically: when psychoanalysis was the only significant force in psychotherapy, it failed to advance
the care of people with mental health problems. Behaviour therapy and cognitive behaviour therapy were needed
to do that. Secondly, theoretically: an approach that not only explicitly rejects but also opposes the use of
treatments that deal with crippling symptoms such as anxiety and depression, obsessional rituals, and agoraphobic avoidance has no place in mental health services, which should by definition help service users to reduce distress and disability.6 Finally,
empirically: the development of an accountable healthcare culture by the
National Institute for Health and Clinical Excellence and other mechanisms has resulted in real improvements in
mental healthcare; an approach that rejects outcome measurement has no place in the rapidly evolving and
empirically grounded field of psychological understanding and interventions in mental health.
We can honour our traditions in mental health, but that does not mean that we should preserve traditions when
we work with NHS service users to help them find pathways to recovery. We suggest that it would be perverse to
provide any place in modern mental health services for psychoanalysis.

Notes
Cite this as: BMJ 2012;344:e1188

Footnotes
• Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have
an interest in the submitted work in the previous three years. PS is editor in chief
of the journal Behavioural and Cognitive Psychotherapy, which is the official journal of the British Association for Behavioural and Cognitive Psychotherapies,
a leading organisation for behavioural and cognitive psychotherapies in the UK. • Does psychoanalysis have a valuable place in modern mental health services? is
the subject of a Maudsley debate at the Institute of Psychiatry, King’s College London on 7 March 2012 (www.iop.kcl.ac.uk/events/?id=1106).
• Provenance and peer review: Commissioned, not externally peer reviewed.

References
1. տ Salkovskis PM. Empirically grounded clinical interventions: cognitive-behavioural therapy progresses
through a multi-dimensional approach to clinical science. Behav Cog Psychother 2002;30:3-9.
2. տ Salkovskis PM. Cognitive therapy and Aaron T Beck. In: Frontiers of cognitive therapy. Guilford
Press, 1996: 533-9.
3. տ Sørensen P, Birket-Smith M, Wattar U, Buemann I, Salkovskis PM. A randomized clinical trial of
cognitive behavioural therapy versus short-term psychodynamic psychotherapy versus no
intervention for patients with hypochondriasis. Psychol Med 2011;41:431-41. CrossRefMedline
4. տ Pribram KH, Gill MM. Freud’s “project” reassessed. Hutchinson, 1976. 5. տ Leader D. A quick fix for the soul. The Guardian2008 Sept 9. 6. տ Yates A. Behaviour therapy and psychodynamic psychotherapy: basic conflict or reconciliation and
integration. Br J Clin Psychol1983;22:107-25.

CrossRef

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