Diluting the Gold of Analysis
Not all psychotherapies are created equal.
Posted Aug 11, 2017
A well-respected colleague once told me that classical psychoanalysis is like an original Rembrandt and the newer, "evidence-based" therapies are like a cheap impostor, pretending to be equal (or even superior) to the original but failing miserably when faced with any critical scrutiny. Having seen hundreds of patients who have been treated off-and-on for years with drugs and the newer therapies only to present to me later for psychoanalysis, I can say that this analogy is a fitting one.
If a person were to consult a psychiatrist in the 1950s or 1960s, he or she would likely be seen three or four times a week for fifty minutes, would lie on the couch, and would relay their dreams, their memories, their fantasies--the innermost content of their minds and lives. The goal was self-understanding, freedom, autonomy. Sometimes a drug would be prescribed, but this was by far the exception rather than the rule. And it was usually a single drug, used judiciously, over the short-term, to aid the process of analysis.
Nowadays, of course, a psychiatrist may see four or five patients an hour, each patient once every three months, and know little to nothing about the patient's personal life and background. Many psychiatrists don't even recall the names of the people who have entrusted them with their "mental health." The patient may be on four, five, six, seven, or more psychotropic drugs and referred to a "therapist" for some sort of brief counseling which nowadays consists of telling the patient how to think or what to do. Long gone are the days of psychoanalytic psychiatry, the use of the couch, and the introspective therapy process. Or so you thought.
Psychoanalysis and psychoanalytic psychotherapy continue to be practiced in some corners of psychiatry, social work, and psychology, and recent research shows that these approaches are more effective than cognitive behavioral therapy over the long-term (Steinert, Munder, Rabung, Hoyer, & Leichsenring, 2017). Psychoanalysis and psychoanalytic therapy are particularly useful, in my opinion, for patients with complex problems, who find themselves engaging in the same problematic behavior repeatedly despite effort at change, and for patients seeking a theoretically- and philosophically-informed critical self-examination. I have been told repeatedly by patients that therapies which focus on "coping skills" and strategies to change their thinking or behavior are mere superficial fixes; what they have been seeking--and what it is that ultimately helps them--is a more complete understanding of the nature of their problems in living. And this understanding can only be obtained via a psychoanalytically-informed psychotherapy, or psychoanalysis.
Despite the field's trend toward shorter, symptom-focused therapies like drugs and CBT, psychoanalysis remains in some cases the only way to conceptualize some psychiatric conditions. The most interesting problem in psychiatry, and perhaps all of medicine, is the patient who presents with neurological symptoms (e.g., paralysis, blindness, seizure, gait disturbance) for which there is no neurologic cause. The problems are psychogenic and the manifestation of internal psychical conflict. This is the type of problem which led Freud to develop his theory of the unconscious mind and forever change the course of psychiatry and medicine. Over one hundred years later, there remains no treatment for conversion disorder other than psychoanalysis, a testament to Freud's enduring genius.
In addition to conversion, psychoanalytic treatment remains the treatment of choice for other conditions such as the personality disorders and other chronic, unrelenting psychiatric syndromes. It is, in the opinion of many, the gold standard of psychiatric treatment--the most intensive, most complex, and most thorough form of treatment available in psychiatry. Despite the field's propensity towards the "quick fix" of drugs and directive therapy, psychoanalysis continues to offer what the other approaches cannot--a full and total examination and understanding of a person's mental life and being of self.
Steinert, C., Munder, T., Rabung, S., Hoyer, J., & Leichsenring, F. (2017). Psychodynamic therapy: As efficacious as other empirically supported treatments? A meta-analysis testing equivalence of outcomes. American Journal of Psychiatry. Advance online publication.