From the Editor
Sigmund Freud is dead.
Are his ideas dead, too?
Psychiatry has left much of Freudian analysis behind. Is that a good thing? This week’s Reading ponders this question – first, with an excellent essay by The Guardian’s Oliver Burkeman that considers “the revenge of Freud,” then with a response from New York Magazine’s Jesse Singal, and, finally, with a recent paper from The American Journal of Psychiatry comparing patients with bulimia who received psychoanalysis and who received CBT.
“Therapy wars: the revenge of Freud”
Oliver Burkeman, The Guardian, 7 January 2016
Dr. David Pollens is a psychoanalyst who sees his patients in a modest ground-floor office on the Upper East Side of Manhattan, a neighbourhood probably only rivalled by the Upper West Side for the highest concentration of therapists anywhere on the planet. Pollens, who is in his early 60s, with thinning silver hair, sits in a wooden armchair at the head of a couch; his patients lie on the couch, facing away from him, the better to explore their most embarrassing fears or fantasies. Many of them come several times a week, sometimes for years, in keeping with analytic tradition. He has an impressive track record treating anxiety, depression and other disorders in adults and children, through the medium of uncensored and largely unstructured talk.
To visit Pollens, as I did one dark winter’s afternoon late last year, is to plunge immediately into the arcane Freudian language of ‘resistance’ and ‘neurosis’, ‘transference’ and ‘counter-transference’. He exudes a sort of warm neutrality; you could easily imagine telling him your most troubling secrets. Like other members of his tribe, Pollens sees himself as an excavator of the catacombs of the unconscious: of the sexual drives that lurk beneath awareness; the hatred we feel for those we claim to love; and the other distasteful truths about ourselves we don’t know, and often don’t wish to know.
But there’s a very well-known narrative when it comes to therapy and the relief of suffering – and it leaves Pollens and his fellow psychoanalysts decisively on the wrong side of history.
But is Pollens on the wrong side of history but fundamentally right? Burkeman mulls this question. He traces the rise of CBT, describes its attraction and impact on practice and public policy, but also notes problems.
This essay is enlivened by great writing and a great story. Cognitive behavioural therapy is profoundly different than psychoanalysis – it is focused, short, and practical, in contrast to the sweeping and romantic nature of analysis – making the story of its rise (and the fall of analysis) all the more dramatic. Burkeman talks about Albert Ellis, the psychoanalysis who concludes: “Freud was full of horseshit!” He notes the strengths of CBT. But he also pushes further, interviewing critics like the University of Colorado’s Jonathan Shedler, a psychologist. Shedler pans CBT with surgical precision: “every thoughtful person knows that self-understanding isn’t something you get from the drive-thru…”
There are really two essays here. First, Burkeman writes an interesting essay on CBT and its critics. Second, Burkeman writes a less critical piece waxing nostalgic for psychoanalysis. The latter ‘essay within the essay’ touches on a few studies but gives light treatment of the literature.
You can read the full essay and draw your own conclusions. For the record, I think that the criticisms of CBT are important to consider (even if you are bullish on CBT); for the record, I think the consideration of analysis is less persuasive – after all, to use an analogy, a market economy may have problems but that doesn’t necessarily mean that the proponents of feudalism are right.
“Is Psychoanalysis Mounting a New Challenge to Cognitive Behavioral Therapy?”
Jesse Singal, New York Magazine (online), 8 January 2016
If you ask the average right-thinking person who follows psychological research what forms of therapy do and don’t work, here’s a likely answer: Cognitive behavioral therapy, which focuses on getting patients to recognize and disrupt certain types of harmful thought patterns, works. Freudian psychoanalysis, which tends to be a longer-term explanation of how patients’ reactions to life and their behavior in relationships are shaped by roiling unconscious forces, many of them stemming from childhood events, is mostly bunk.
Writing in The Guardian, Oliver Burkeman has a long article that complicates this view in intelligent, provocative ways, and it’s very much worth reading for anyone interested in practical questions about the effectiveness of therapy, the trickiness of studying behavioral science, or both.
So begins Singal’s response to Burkeman’s essay. Singal doesn’t quite debate Burkeman, but he does raise some important things to consider in the CBT vs. psychoanalysis debate.
Singal makes three central points.
1. “Let’s not lump together a therapy and the way it might be administered.”
2. “We can’t talk about psychological treatment without talking about resource constraints.”
3. “It’s hard to separate out the benefits of psychoanalysis from the benefits of just having someone to talk to.”
His piece is short (maybe too short) and it can be read quickly. I don’t need to provide much of a summary.
I will draw attention to the second point, though, as it’s particularly important. Singal is an American writing about a health-care system that is very different from ours. Still, the issue of resource allocation is important there, here – and everywhere. With scarce resources, economics needs to be considered. After all, it would be ridiculous to think about buying a car without mulling the price of your potential choice – or your budget. The Bentley Flying Spur is a great car, but not necessarily a great pick if it means that you wouldn’t be able to pay for food.
CBT vs. Analysis
“A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa”
Stig Poulsen et al., The American Journal of Psychiatry, January 2014
In Denmark and other European countries, longer-term psychoanalytic psychotherapy has been widely practiced as a treatment for eating disorders. However, research has focused on cognitive-behavioral therapy (CBT), which has proven efficacious as a treatment for bulimia nervosa in several randomized controlled studies. Nevertheless, since most bulimia patients remain symptomatic following this treatment, there is a need to develop alternative treatment approaches for this disorder. It has been proposed that a central feature of bulimia nervosa is the inability to tolerate and regulate affective experience and that the bulimia symptoms serve as an attempt to avoid negative affect. Because a general aim of psychoanalytic psychotherapy is to increase the capacity to recognize and tolerate affects, it was hypothesized that psychoanalytic psychotherapy would result in a reduction of binging and purging through the facilitation of heightened affect tolerance and insight into the psychological function of the symptoms.
Accordingly, the purpose of the present study was to test the efficacy of a longer-term psychoanalytic psychotherapeutic treatment specifically designed for patients with bulimia nervosa by comparing it with the ‘enhanced’ version of the original CBT.
So begins an interesting study: in this paper from The American Journal of Psychiatry, the authors do a direct comparison of psychoanalysis with CBT. It’s the Frazier-Ali of psychotherapy studies (a cultural reference that most of you will need to google…). Of course, perspective is important: let’s remember that this is just one study and it looks at one psychiatric illness. Still, as entertaining as points made by Burkeman and Singal are, it’s nice to tie back to the literature.
Here’s what they did:
· 70 patients with bulimia were randomly selected to the two types of psychotherapy.
· The patients were recruited through a university clinic. Inclusion criteria included meeting criteria for bulimia nervosa (DSM-IV definition) and availability for the full treatment; exclusion criteria included: pregnancy, current psychotherapy, difficulty speaking Danish.
· The people assigned to psychoanalysis were treated with weekly 50-minute sessions for 2 years, with a therapy specifically designed for people with bulimia (among other things: an emphasis on the patient speaking freely and mutual reflection).
· The people assigned to the CBT treatment were offered 20 sessions over 5 months, with the therapy designed for people with eating disorders (so, for example, there was a focus on modifying concerns about shape and weight).
· Several scales were used, including the Present State Examination and the Beck Depression Inventory-II.
· Different statistical analyses were used.
Here’s what they found:
· Of the 34 assigned to analysis, 24 completed (70.6%). Of the 36 assigned to CBT, 28 completed (77.8%).
· Demographically: the vast majority were in their 20s, women, and childless.
· At their respective endpoints, 15 (42%) of the CBT patients stopped binge eating and purging but only 5 (15%) of the analysis patients did.
· Over time, response varied. CBT patients got better faster and stayed better in terms of binge and purge patterns. (See below.)
· In terms of global eating disorder psychopathology, patients improved with both treatments – though, again, tended to improve faster with CBT. At two years, the difference between the two groups wasn’t statistically significant.
The authors conclude with a partial endorsement of the CBT approach:
First, CBT is the preferred treatment for the disorder when compared with the version of psychoanalytic psychotherapy tested in this trial. Second, at the 2-year follow-up, 56% of the patients in CBT still had episodes of binge eating and purging, 31% still met the diagnostic criteria for bulimia nervosa, and several patients received additional treatment during follow-up. Accordingly, further treatment developments are needed.
A few thoughts:
· This is a good study.
· Poulsen et al. do a nice comparison of CBT vs. psychoanalysis and find differences, with CBT providing faster symptom relief, particularly for binging and purging.
· That said, to pick up on the second point made by Singal: comparing different therapies should consider resource needs. Poulsen et al. didn’t do an economic analysis, but it’s difficult not to think that CBT would be a fraction of the price of the analysis treatment.
Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.