Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence based.” In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings.
There is a belief in some quarters that psychodynamic concepts and treatments lack empirical support or that scientific evidence shows that other forms of treatment are more effective. The belief appears to have taken on a life of its own. Academicians repeat it to one another, as do health care administrators, as do health care policymakers. With each repetition, its apparent credibility grows. At some point, there seems little need to question or revisit it because “everyone” knows it to be so.
The scientific evidence tells a different story: Considerable research supports the efficacy and effectiveness of psychodynamic therapy. The discrepancy between perceptions and evidence may be due, in part, to biases in the dissemination of research findings. One potential source of bias is a lingering distaste in the mental health professions for past psychoanalytic arrogance and authority. In decades past, American psychoanalysis was dominated by a hierarchical medical establishment that denied training to non- MDs and adopted a dismissive stance toward research. This stance did not win friends in academic circles. When empirical findings emerged that supported nonpsychodynamic treatments, many academicians greeted them enthusiastically and were eager to discuss and disseminate them. When empirical evidence supported psychodynamic concepts and treatments, it was often overlooked.
This article brings together findings from several empirical literatures that bear on the efficacy of psychodynamic treatment. I first outline the distinctive features of psychodynamic therapy. I next review empirical evidence for the efficacy of psychodynamic treatment, including evidence that patients who receive psychodynamic therapy not only maintain therapeutic gains but continue to improve over time. Finally, I consider evidence that nonpsychodynamic therapies may be effective in part because the more skilled practitioners utilize interventions that have long been central to psychodynamic theory and practice.
Distinctive Features of Psychodynamic Technique Psychodynamic or psychoanalytic psychotherapy1 refers to a range of treatments based on psychoanalytic concepts and methods that involve less frequent meetings and may be considerably briefer than psychoanalysis proper. Session frequency is typically once or twice per week, and the treatment may be either time limited or open ended. The essence of psychodynamic therapy is exploring those aspects of self that are not fully known, especially as they are manifested and potentially influenced in the therapy relationship. Undergraduate textbooks too often equate psychoanalytic or psychodynamic therapies with some of the more outlandish and inaccessible speculations made by Sigmund Freud roughly a century ago, rarely presenting mainstream psychodynamic concepts as understood and practiced today.
Such presentations, along with caricatured depictions in the popular media, have contributed to widespread misunderstanding of psychodynamic treatment (for discussion of how clinical psychoanalysis is represented and misrepresented in undergraduate curricula, see Bornstein, 1988, 1995; Hansell, 2005; Redmond & Shulman, 2008). To help dispel possible myths and facilitate greater understanding of psychodynamic practice, in this section I review core features of contemporary psychodynamic technique. Blagys and Hilsenroth (2000) conducted a search of the PsycLit database to identify empirical studies that compared the process and technique of manualized pychodynamic therapy with that of manualized cognitive behavioral therapy (CBT). Seven features reliably distinguished psychodynamic therapy from other therapies, as determined by empirical examination of actual session recordings and I thank Mark Hilsenroth for his extensive contributions to this article; Marc Diener for providing some of the information reported here; Robert Feinstein, Glen Gabbard, Michael Karson, Kenneth Levy, Nancy McWilliams, Robert Michels, George Stricker, and Robert Wallerstein for their comments on drafts of the article; and the 500-plus members of the Psychodynamic Research Listserv for their collective wisdom and support.
I use the terms psychoanalytic and psychodynamic interchangeably.
1. Focus on affect and expression of emotion. Psychodynamic therapy encourages exploration and discussion of the full range of a patient’s emotions. The therapist helps the patient describe and put words to feelings, including contradictory feelings, feelings that are troubling or threatening, and feelings that the patient may not initially be able to recognize or acknowledge (this stands in contrast to a cognitive focus, where the greater emphasis is on thoughts and beliefs.) There is also a recognition that intellectual insight is not the same as emotional insight, which resonates at a deep level and leads to change (this is one reason why many intelligent and psychologically minded people can explain the reasons for their difficulties, yet their understanding does not help them overcome those difficulties).
2. Exploration of attempts to avoid distressing thoughts and feelings. People do a great many things, knowingly and unknowingly, to avoid aspects of experience that are troubling. This avoidance (in theoretical terms, defense and resistance) may take coarse forms, such as missing sessions, arriving late, or being evasive. It may take subtle forms that are difficult to recognize in ordinary social discourse, such as subtle shifts of topic when certain ideas arise, focusing on incidental aspects of an experience rather than on what is psychologically meaningful, attending to facts and events to the exclusion of affect, focusing on external circumstances rather than one’s own role in shaping events, and so on. Psychodynamic therapists actively focus on and explore avoidances.
3. Identification of recurring themes and patterns. Psychodynamic therapists work to identify and explore recurring themes and patterns in patients’ thoughts, feelings, self-concept, relationships, and life experiences. In some cases, a patient may be acutely aware of recurring patterns that are painful or self-defeating but feel unable to escape them (e.g., a man who repeatedly finds himself drawn to romantic partners who are emotionally unavailable; a woman who regularly sabotages herself when success is at hand). In other cases, the patient may be unaware of the patterns until the therapist helps him or her recognize and understand them.
4. Discussion of past experience (developmental focus). Related to the identification of recurring themes and patterns is the recognition that past experience, especially early experiences of attachment figures, affects our relation to, and experience of, the present. Psychodynamic therapists explore early experiences, the relation between past and present, and the ways in which the past tends to “live on” in the present. The focus is not on the past for its own sake, but rather on how the past sheds light on current psychological difficulties. The goal is to help patients free themselves from the bonds of past experience in order to live more fully in the present.
5. Focus on interpersonal relations. Psychodynamic therapy places heavy emphasis on patients’ relationships and interpersonal experience (in theoretical terms, object relations and attachment). Both adaptive and nonadaptive aspects of personality and self-concept are forged in the context of attachment relationships, and psychological difficulties often arise when problematic interpersonal patterns interfere with a person’s ability to meet emotional needs.
6. Focus on the therapy relationship. The relationship between therapist and patient is itself an important interpersonal relationship, one that can become deeply meaningful and emotionally charged. To the extent that there are repetitive themes in a person’s relationships and manner of interacting, these themes tend to emerge in some form in the therapy relationship. For example, a person prone to distrust others may view the therapist with suspicion; a person who fears disapproval, rejection, or abandonment may fear rejection by the therapist, whether knowingly or unknowingly; a person who struggles with anger and hostility may struggle with anger toward the therapist; and so on (these are relatively crude examples; the repetition of interpersonal themes in the therapy relationship is often more complex and subtle than these examples suggest). The recurrence of interpersonal themes in the therapy relationship (in theoretical terms, transference and countertransference) provides a unique opportunity to explore and rework them in vivo. The goal is greater flexibility in interpersonal relationships and an enhanced capacity to meet interpersonal needs.
7. Exploration of fantasy life. In contrast to other therapies in which the therapist may actively structure sessions or follow a predetermined agenda, psychodynamic therapy encourages patients to speak freely about whatever is on their minds. When patients do this (and most patients require considerable help from the therapist before they can truly speak freely), their thoughts naturally range over many areas of mental life, including desires, fears, fantasies, dreams, and daydreams (which in many cases the patient has not previously attempted to put into words). All of this material is a rich source of information about how the person views self and others, interprets and makes sense of experience, avoids aspects of experience, or interferes with a potential capacity to find greater enjoyment and meaning in life.
The last sentence hints at a larger goal that is implicit.in all of the others: The goals of psychodynamic therapy include, but extend beyond, symptom remission. Successful treatment should not only relieve symptoms (i.e., get rid of something) but also foster the positive presence of psychological capacities and resources. Depending on the person and the circumstances, these might include the capacity to have more fulfilling relationships, make more effective use of one’s talents and abilities, maintain a realistically based sense of self-esteem, tolerate a wider range of affect, have more satisfying sexual experiences, understand self and others in more nuanced and sophisticated ways, and face life’s challenges with greater freedom and flexibility. Such ends are pursued through a process of self-reflection, self-exploration, and self-discovery that takes place in the context of a safe and deeply authentic relationship between therapist and patient.
How Effective Is Psychotherapy in General?
In psychology and in medicine more generally, meta-analysis is a widely accepted method for summarizing and synthesizing the findings of independent studies (Lipsey & Wilson, 2001; Rosenthal, 1991; Rosenthal & DiMatteo, 2001). Meta-analysis makes the results of different studies comparable by converting findings into a common metric, allowing findings to be aggregated or pooled across studies. A widely used metric is effect size, which is the difference between treatment and control groups, expressed in standard deviation units.2 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 (Cohen, 1988).
The first major meta-analysis of psychotherapy outcome studies included 475 studies and yielded an overall effect size (various diagnoses and treatments) of 0.85 for patients who received psychotherapy compared with untreated controls (Smith, Glass, & Miller, 1980). Subsequent meta-analyses have similarly supported the efficacy of psychotherapy. The influential review by Lipsey and Wilson (1993) tabulated results for 18 meta-analyses concerned with general psychotherapy outcomes, which had a median effect size of 0.75. It also tabulated results for 23 metaanalyses concerned with outcomes in CBT and behavior modification, which had a median effect size of .62. A meta-analysis by Robinson, Berman, and Neimeyer (1990) summarized the findings of 37 psychotherapy studies concerned specifically with outcomes in the treatment of depression, which had an overall effect size of 0.73. These are relatively large effects.
To provide some points of reference, it is instructive to consider effect sizes for antidepressant medications. An analysis of U.S. Food and Drug Adminstration (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 (Turner, Matthews, Linardatos, Tell, & Rosenthal, 2008).3 A meta-analysis reported in the prestigious Cochrane Library (Moncrieff, Wessely, & Hardy, 2004) found an effect size of 0.17 for tricyclic antidepressants compared with active placebo (an active placebo mimics the side effects of an antidepressant drug but is not itself an antidepressant).4 These are relatively small effects. Methodological differences between medication trials and psychotherapy trials are sufficiently great that effect sizes may not be directly comparable, and the findings should not be interpreted as conclusive evidence that psychotherapy is more effective.
Effect sizes for antidepressant medications are reported to provide reference points that will be familiar to many readers (for more comprehensive listings of effect size reference points, see, e.g., Lipsey & Wilson, 1993; Meyer et al., 2001). 2 This score, known as the standardized mean difference, is used to summarize the findings of randomized control trials. More broadly, the concept effect size may refer to any measure that expresses the magnitude of a research finding (Rosenthal & Rosnow, 2008). 3 The measure of effect size in this study was Hedges’ g (Hedges, 1982) rather than Cohen’s d (Cohen, 1988), which is more commonly reported. The two measures are based on slightly different computational formulas, but in this case the choice of formula would have made no difference: “Because of the large sample size (over 12,000), there is no change in going from g to d; both values are .31 to two decimal places” (R. Rosenthal, personal communication to Marc Diener, January 2008). 4 Although antidepressant trials are intended to be double-blind, the blind is easily penetrated because the adverse side effects of antidepressant medications are physically discernible and widely known. Study participants and their doctors can therefore figure out whether they are receiving medication or placebo, and effects attributed to medication may be inflated by expectancy and demand effects. Use of “active” placebos better protects the blind, and the resulting effect sizes are approximately half as large as those otherwise reported.
A recent and especially methodologically rigorous metaanalysis of psychodynamic therapy, published by the Cochrane Library,5 included 23 randomized controlled trials of 1,431 patients (Abbass, Hancock, Henderson, & Kisely, 2006). The studies compared patients with a range of common mental disorders6 who received shortterm (40 hours) psychodynamic therapy with controls (wait list, minimal treatment, or “treatment as usual”) and yielded an overall effect size of 0.97 for general symptom improvement. The effect size increased to 1.51 when the patients were assessed at long-term follow-up ( 9 months posttreatment). In addition to change in general symptoms, the meta-analysis reported an effect size of 0.81 for change in somatic symptoms, which increased to 2.21 at long-term follow-up; an effect size of 1.08 for change in anxiety ratings, which increased to 1.35 at follow-up; and an effect size of 0.59 for change in depressive symptoms, which increased to 0.98 at follow-up.7 The consistent trend toward larger effect sizes at follow-up suggests that psychodynamic therapy sets in motion psychological processes that lead to ongoing change, even after therapy has ended.
A meta-analysis published in Archives of General Psychiatry included 17 high-quality randomized controlled trials of short-term (average of 21 sessions) psychodynamic therapy and reported an effect size of 1.17 for psychodynamic therapy compared with controls (Leichsenring, Rabung, & Leibing, 2004). The pretreatment to posttreatment effect size was 1.39, which increased to 1.57 at long-term follow-up, which occurred an average of 13 months posttreatment. Translating these effect sizes into percentage terms, the authors noted that patients treated with psychodynamic therapy were “better off with regard to their target problems than 92% of the patients before therapy” (Leichsenring et al., 2004, p. 1213).
A newly released meta-analysis examined the efficacy of short-term psychodynamic therapy for somatic disorders (Abbass, Kisely, & Kroenke, 2009). It included 23 studies involving 1,870 patients who suffered from a wide range of somatic conditions (e.g., dermatological, neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, genitourinary, immunological). The study reported effect sizes of 0.69 for improvement in general psychiatric symptoms and 0.59 for improvement in somatic symptoms.
Among studies that reported data on health care utilization, 77.8% reported reductions in health care utilization that were due to psychodynamic therapy—a finding with potentially enormous implications for health care reform.
A meta-analysis reported in the American Journal of Psychiatry examined the efficacy of both psychodynamic psychotherapy (14 studies) and CBT (11 studies) for personality disorders (Leichsenring & Leibing, 2003). The metaanalysis reported pretreatment to posttreatment effect sizes using the longest term follow-up available. For psychodynamic therapy (mean length of treatment was 37 weeks), the mean follow-up period was 1.5 years and the pretreatment to posttreatment effect size was 1.46. For CBT (mean length of treatment was 16 weeks), the mean follow-up period was 13 weeks and the effect size was 1.0. The authors concluded that both treatments demonstrated effectiveness. A more recent review of short-term (average of 30.7 sessions) psychodynamic therapy for personality disorders included data from seven randomized controlled trials (Messer & Abbass, in press). 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).
Two recent studies examined the efficacy of longterm psychodynamic treatment. A meta-analysis reported in the Journal of the American Medical Association (Leichsenring & Rabung, 2008) compared longterm 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.8 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. Effect sizes increased from treatment completion to follow-up for all five outcome domains assessed in the study (overall effectiveness, target problems, psychiatric symptoms, personality functioning, and social functioning).
A second meta-analysis, reported in the Harvard Review of Psychiatry (de Maat, de Jonghe, schoevers, & Dekker, 2009), examined the effectiveness of long-term psychodynamic therapy (average of 150 sessions) for adult outpatients with a range of diagnoses. For patients with mixed/moderate pathology, the pretreatment to posttreatment effect was 0.78 for general symptom improvement, which increased to 0.94 at long-term follow-up, an average of 3.2 years posttreatment. For patients with severe personality pathology, the pretreatment to posttreatment effect was 0.94, which increased to 1.02 at long-term follow-up, an average of 5.2 years posttreatment.
These meta-analyses represent the most recent and methodologically rigorous evaluations of psychodynamic therapy. Especially noteworthy is the recurring finding that the benefits of psychodynamic therapy not only is 5 more widely known in medicine than in psychology, the Cochrane Library was created to promote evidence based practice and is considered a leader in methodological rigor for meta-analysis. 6 These included nonpsychotic symptom and behavior disorders commonly seen in primary care and psychiatric services, for example, nonbipolar depressive disorders, anxiety disorders, and somatoform disorders, often mixed with interpersonal or personality disorders (Abbass et al., 2006). 7 The meta-analysis computed effect sizes in a variety of ways. The findings reported here are based on the single method that seemed mostconcept ually and statistically meaningful (in this case, a random effects model, with a single outlier excluded). See the original source for more fine-grained analyses (Abbass et al., 2006). 8 The atypical method used to compute this effect size may provide an inflated estimate of efficacy, and the effect size may not be comparable to other effect sizes reported in this review (for discussion, see Thombs, Bassel, & Jewett, 2009). That benfits not only endure but increase with time, a finding that has now emerged from at least five independent meta-analyses (Abbass et al., 2006; Anderson & Lambert, 1995; de Maat et al., 2009; Leichsenring & Rabung, 2008; Leichsenring et al., 2004).
In contrast, the benefits of other (nonpsychodynamic) empirically supported therapies tend to decay over time for the most common disorders (e.g., depression, generalized anxiety; de Maat, Dekker, Schoevers, & de Jonghe, 2006; Gloaguen, Cottraux, Cucharet, & Blackburn, 1998; Hollon et al., 2005; Westen, Novotny, & Thompson- Brenner, 2004). 9 Table 1 summarizes the meta-analytic findings described above and adds additional findings to provide further points of reference. Except as noted, effect sizes listed in the table are based on comparisons of treatment and control groups and reflect response at the completion of treatment (not long-term follow-up). Studies supporting the efficacy of psychodynamic therapy span a range of conditions and populations. Randomized controlled trials support the efficacy of psychodynamic therapy for depression, anxiety, panic, somatoform disorders, eating disorders, substance-related disorders, and personality disorders (Leichsenring, 2005; Milrod et al., 2007).
Findings concerning personality disorders are particularly intriguing. A recent study of patients with borderline personality disorder (Clarkin, Levy, Lenzenweger, & Kernberg, 2007) not only demonstrated treatment benefits that equaled or exceeded those of another evidence-based treatment, dialectical behavior therapy (Linehan, 1993), but 9 The exceptions to this pattern are specific anxiety conditions such as panic disorder and simple phobia, for which short-term, manualized treatments do appear to have lasting benefits (Westen et al., 2004). (See table 1 in PDF version) also showed changes in underlying psychological mechanisms (intrapsychic processes) believed to mediate symptom change in borderline patients (specifically, changes in reflective function and attachment organization; Levy et al., 2006). These intrapsychic changes occurred in patients who received psychodynamic therapy but not in patients who received dialectical behavior therapy.
Such intrapsychic changes may account for long-term treatment benefits. A newly released study showed enduring benefits of psychodynamic therapy five years after treatment completion (and eight years after treatment initiation). At five-year follow-up, 87% of patients who received “treatment as usual” continued to meet diagnostic criteria for borderline personality disorder, compared with 13% of patients who received psychodynamic therapy (Bateman & Fonagy, 2008). No other treatment for personality pathology has shown such enduring benefits. These last findings must be tempered with the caveat that they rest on two studies and therefore cannot carry as much evidential weight as findings replicated in multiple studies conducted by independent research teams. More generally, it must be acknowledged that there are far more empirical outcome studies of other treatments, notably CBT, than of psychodynamic treatments.
The discrepancy in sheer numbers of studies is traceable, in part, to the indifference to empirical research of earlier generations of psychoanalysts, a failing that continues to haunt the field and that contemporary investigators labor to address. A second caveat is that many psychodynamic outcome studies have included patients with a range of symptoms and conditions rather than focusing on specific diagnostic categories (e.g., those defined by diagnostic criteria specified in the Diagnostic and Statistical Manual of Mental Disorders [4th edition, DSM-IV; American Psychiatric Association, 1994]). The extent to which this is a limitation is open to debate. A concern often raised about psychotherapy efficacy studies is that they use highly selected and unrepresentative patient samples and, consequently, that their findings do not generalize to real-world clinical practice (e.g., Westen et al., 2004). Nor is there universal agreement that DSM–IV diagnostic categories define discrete or homogeneous patient groups (given that psychiatric comorbidity is the norm and that diagnosable complaints are often embedded in personality syndromes; Blatt & Zuroff, 2005; Westen, Gabbard, & Blagov, 2006). Be that as it may, an increasing number of studies of psychodynamic treatments do focus on specific diagnoses (e.g., Bateman & Fonagy, 2008; Clarkin et al., 2007; Cuijpers, van Straten, Andersson, & van Oppen, 2008; Leichsenring, 2001, 2005; Milrod et al., 2007).
A Rose by Another Name: Psychodynamic Process in Other Therapies
The “active ingredients” of therapy are not necessarily those presumed by the theory or treatment model. For this reason, randomized controlled trials that evaluate a therapy as a “package” do not necessarily provide support for its theoretical premises or the specific interventions that derive from them. For example, the available evidence indicates that the mechanisms of change in cognitive therapy (CT) are not those presumed by the theory. Kazdin (2007), reviewing the empirical literature on mediators and mechanisms of change in psychotherapy, concluded, “Perhaps we can state more confidently now than before that whatever may be the basis of changes with CT, it does not seem to be the cognitions as originally proposed” (p. 8).
There are also profound differences in the way therapists practice, even therapists ostensibly providing the same treatment. What takes place in the clinical consulting room reflects the qualities and style of the individual therapist, the individual patient, and the unique patterns of interaction that develop between them. Even in controlled studies designed to compare manualized treatments, therapists interact with patients in different ways, implement interventions differently, and introduce processes not specified by the treatment manuals (Elkin et al., 1989). In some cases, investigators have had difficulty determining from verbatim session transcripts which manualized treatment was being provided (Ablon & Jones, 2002). For these reasons, studies of therapy “brand names” can be highly misleading. Studies that look beyond brand names by examining session videotapes or transcripts may reveal more about what is helpful to patients (Goldfried & Wolfe, 1996; Kazdin, 2007, 2008). Such studies indicate that the active ingredients of other therapies include unacknowledged psychodynamic elements.
One method of studying what actually happens in therapy sessions makes use of the Psychotherapy Process Q-Sort (PQS; Jones, 2000). This instrument consists of 100 variables that assess therapist technique and other aspects of the therapy process based on specific actions, behaviors, and statements made during sessions. In a series of studies, blind raters scored the 100 PQS variables from archival, verbatim session transcripts for hundreds of therapy hours from outcome studies of both brief psychodynamic therapy and CBT (Ablon & Jones, 1998; Jones & Pulos, 1993).10 In one study, the investigators asked panels of internationally recognized experts in psychoanalytic therapy and CBT to use the PQS to describe “ideally” conducted treatments (Ablon & Jones, 1998). On the basis of the expert ratings, the investigators constructed prototypes of ideally conducted psychodynamic therapy and CBT. The two prototypes differed considerably.
The psychodynamic prototype emphasized unstructured, open-ended dialogue (e.g., discussion of fantasies and dreams); identifying recurring themes in the patient’s experience; linking the patient’s feelings and perceptions to past experiences; drawing attention to feelings regarded by the patient as unacceptable (e.g., anger, envy, excitement); pointing out defensive maneuvers; interpreting warded-off 10 The cognitive therapy study was a randomized controlled trial for depression; the psychodynamic therapy studies were panel studies for mixed disorders and for posttraumatic stress disorder, respectively or unconscious wishes, feelings, or ideas; focusing on the therapy relationship as a topic of discussion; and drawing connections between the therapy relationship and other relationships.
The CBT prototype emphasized dialogue with a more specific focus, with the therapist structuring the interaction and introducing topics; the therapist functioning in a more didactic or teacher-like manner; the therapist offering explicit guidance or advice; discussion of the patient’s treatment goals; explanation of the rationale behind the treatment and techniques; focusing on the patient’s current life situation; focusing on cognitive themes such as thoughts and belief systems; and discussion of tasks or activities (“homework”) for the patient to attempt outside of therapy sessions.
In three sets of archival treatment records (one from a study of cognitive therapy and two from studies of brief psychodynamic therapy), the researchers measured therapists’ adherence to each therapy prototype without regard to the treatment model the therapists believed they were applying (Ablon & Jones, 1998). Therapist adherence to the psychodynamic prototype predicted successful outcome in both psychodynamic and cognitive therapy. Therapist adherence to the CBT prototype showed little or no relation to outcome in either form of therapy. The findings replicated those of an earlier study that employed a different methodology and also found that psychodynamic interventions, not CBT interventions, predicted successful outcome in both cognitive and psychodynamic treatments (Jones & Pulos, 1993). An independent team of investigators using different research methods also found that psychodynamic methods predicted successful outcome in cognitive therapy (Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996). The study assessed outcomes in cognitive therapy conducted according to Beck’s treatment model (Beck, Rush, Shaw, & Emery, 1979), and the findings had been reported as evidence for the efficacy of cognitive therapy for depression (Hollon et al., 1992).12
Investigators measured three variables from verbatim transcripts of randomly selected therapy sessions in a sample of 64 outpatients. One variable assessed quality of the working alliance (the concept working alliance, or therapeutic alliance, is now widely recognized and often considered a nonspecific or “common” factor in many forms of therapy; many do not realize that the concept comes directly from psychoanalysis and has played a central role in psychoanalytic theory and practice for over four decades; see Greenson, 1967; Horvath & Luborsky, 1993). The second variable assessed therapist implementation of the cognitive treatment model (i.e., addressing distorted cognitions believed to cause depressive affect). The third variable, labeled experiencing, beautifully captures the essence of psychoanalytic process:
At the lower stages of [experiencing], the client talks about events, ideas, or others (Stage 1); refers to self but without expressing emotions (Stage 2); or expresses emotions but only as they relate to external circumstances (Stage 3). At higher stages, the client focuses directly on emotions and thoughts about self (Stage 4), engages in an exploration of his or her inner experience (Stage 5), and gains awareness of previously implicit feelings and meanings [emphasis added] (Stage 6). The highest stage (7) refers to an ongoing process of in-depth self- understanding. (Castonguay et al., 1996, p. 499) Especially noteworthy is the phrase “gains awareness of previously implicit feelings and meanings.” The term implicit refers, of course, to aspects of mental life that are not initially conscious. The construct measured by the scale hearkens back to the earliest days of psychoanalysis and its central goal of making the unconscious conscious (Freud, 1896/1962).13
In this study of manualized cognitive therapy for depression, the following findings emerged: (a) Working alliance predicted patient improvement on all outcome measures; (b) psychodynamic process (“experiencing”) predicted patient improvement on all outcome measures; and (c) therapist adherence to the cognitive treatment model (i.e., focusing on distorted cognitions) predicted poorer outcome. A subsequent study using different methodology replicated the finding that interventions aimed at cognitive change predicted poorer outcome (Hayes, Castonguay, & Goldfried, 1996). However, discussion of interpersonal relations and exploration of past experiences with early caregivers— both core features of psychodynamic technique—predicted successful outcome. These findings should not be interpreted as indicating that cognitive techniques are harmful, and other studies have reported positive relations between CBT technique and outcome (Feeley, DeRubeis, & Gelfand, 1999; Strunk, DeRubeis, Chiu, & Alvarez, 2007; Tang & DeRubeis, 1999). Qualitative analysis of the verbatim session transcripts suggested that the poorer outcomes associated with cognitive interventions were due to implementation of the cognitive treatment model in dogmatic, rigidly insensitive ways by certain of the therapists (Castonguay et al., 1996) (No school of therapy appears to have a monopoly on dogmatism or therapeutic insensitivity. Certainly, the history of psychoanalysis is replete with examples of dogmatic excesses.)
On the other hand, the findings do indicate that the more effective therapists facilitated therapeutic processes that have long been core, centrally defining features of psychoanalytic theory and practice. Other empirical studies have also demonstrated links between psychodynamic methods and successful outcome, whether or not the investigators explicitly identified the methods as “psychodynamic” (e.g., Barber, Crits-Christoph, & Luborsky, 1996; Diener, Hilsenroth, & Weinberger, 2007; Gaston, Thompson, Gallagher, Cournoyer, & 11 See the original source for more complete descriptions of the two therapy prototypes (Ablon & Jones, 1998). 12 The study is one of the archival studies analyzed by Jones and his associates (Ablon & Jones, 1998; Jones & Pulos, 1993). 13 Although the term “experiencing” derives from the humanistic therapy tradition, the phenomenon assessed by the scale—a trajectory of deepening self-exploration, leading to increased awareness of implicit or unconscious mental life—is the core defining feature of psychoanalysis and psychoanalytic therapy.
The Flight of the Dodo
The heading of this section is an allusion to what has come to be known in the psychotherapy research literature as the Dodo bird verdict. After reviewing the psychotherapy outcome literatures of the time, Rosenzweig (1936), and subsequently Luborsky, Singer, and Luborsky (1975), reached the conclusion of the Dodo bird in Alice in Wonderland: “Everybody has won, and all must have prizes.” Outcomes for different therapies were surprisingly equivalent, and no form of psychotherapy proved superior to any other. In the rare instances when studies found differences between active treatments, the findings virtually always favored the preferred treatment of the investigators (the investigator allegiance effect; Luborsky et al., 1999). Subsequent research has done little to alter the Dodo bird verdict (Lambert & Ogles, 2004; Wampold, Minami, Baskin, & Callen Tierney, 2002). For example, studies that have directly compared CBT with short-term psychodynamic therapy for depression have failed to show greater efficacy for CBT over Psychodynamic therapy or vice versa (Cuijpers et al., 2008; Leichsenring, 2001).
Leichsenring (2001) noted that both treatments appeared to qualify as empirically supported therapies according to the criteria specified by the American Psychological Association’s Division 12 Task Force on Promotion and Dissemination of Psychological Procedures (1995; Chambless et al., 1998). Some of the studies compared psychodynamic treatments of only eight sessions’ duration, which most practitioners would consider inadequate, with 16-session CBT treatments. Even in these studies, outcomes were comparable (Barkham et al., 1996; Shapiro et al., 1994). There are many reasons why outcome studies may fail to show differences between treatments even if important differences really exist. Others have discussed the limitations and unexamined assumptions of current research methods (Goldfried & Wolfe, 1996; Norcross, Beutler, & Levant, 2005; Westen et al., 2004). Here I focus on one salient limitation: the mismatch between what psychodynamic therapy aims to accomplish and what outcome studies typically measure. As noted earlier, the goals of psychodynamic therapy include, but extend beyond, alleviation of acute symptoms.
Psychological health is not merely the absence of symptoms; it is the positive presence of inner capacities and resources that allow people to live life with a greater sense of freedom and possibility. Symptom-oriented outcome measures commonly used in outcome studies (e.g., the Beck Depression Inventory [Beck, Ward, Mendelson, Mock, & Erbaugh, 1961] or the Hamilton Rating Scale for Depression [Hamilton, 1960]) do not attempt to assess such inner capacities (Blatt & Auerbach, 2003; Kazdin, 2008). Possibly, the Dodo bird verdict reflects a failure of researchers, psychodynamic and nonpsychodynamic alike, to adequately assess the range of phenomena that can change in psychotherapy. The Shedler–Westen Assessment Procedure (SWAP; Shedler & Westen, 2007; Westen & Shedler, 1999a, 1999b) represents one method of assessing the kinds of inner capacities and resources that psychotherapy may develop. The SWAP is a clinician-report (not-self report) instrument that assesses a broad range of personality processes, both healthy and pathological. The instrument can be scored by clinicians of any theoretical orientation and has demonstrated high reliability and validity relative to a wide range of criterion measures (Shedler & Westen, 2007; Westen & Shedler, 2007).
The SWAP includes an empirically derived Healthy Functioning Index comprising the items listed in Table 2, (below) which define and operationalize mental health as consensually understood by clinical practitioners across theoretical orientations (Westen & Shedler, 1999a, 1999b). Many forms of treatment, including medications, may be effective in alleviating acute psychiatric symptoms, at least in the short run. However, not all therapies aim at changing underlying psychological processes such as those assessed by the SWAP. Researchers, including psychodynamically oriented researchers, have yet to conduct compelling outcome studies that assess changes in inner capacities and resources, but two studies raise intriguing possibilities and suggest directions for future research.
One is a single case study of a woman diagnosed with borderline personality disorder who was assessed with the SWAP by independent assessors (not the treating clinician) at the beginning of treatment and again after two years of psychodynamic therapy (Lingiardi, Shedler, & Gazzillo, 2006). In addition to meaningful decreases in SWAP scales that measure psychopathology, the patient’s SWAP scores showed an increased capacity for empathy and greater sensitivity to others’ needs and feelings; increased ability to recognize alternative viewpoints, even when emotions ran high; increased ability to comfort and soothe herself; increased recognition and awareness of the consequences of her actions; increased ability to express herself verbally; more accurate and balanced perceptions of people and situations; a greater capacity to appreciate humor; and, perhaps most important, she had come to terms with painful past experiences and had found meaning in them and grown from them. The patient’s score on the SWAP Healthy Functioning Index increased by approximately two standard deviations over the course of treatment.
A second study used the SWAP to compare 26 patients beginning psychoanalysis with 26 patients completing psychoanalysis (Cogan & Porcerelli, 2005). The latter group not only had significantly lower scores for SWAP items assessing depression, anxiety, guilt, shame, feelings of inadequacy, and fears of rejection but significantly higher scores for SWAP items assessing inner strengths and capacities (see Table 2). These included greater satisfaction in pursuing long-term goals, enjoyment of challenges and pleasure in accomplishments, ability to utilize talents and abilities, contentment in life’s activities, empathy for others, interpersonal assertiveness and effectiveness, ability to hear and benefit from emotionally threatening information, and resolution of past painful experiences. For the group completing psychoanalysis, the mean score on the SWAP Healthy Functioning Index was one standard deviation higher. Methodological limitations preclude drawing causal conclusions from these studies, but they suggest that psychodynamic therapy may not only alleviate symptoms but also develop inner capacities and resources that allow a richer and more fulfilling life.
Measures such as the SWAP could be incorporated in future randomized controlled trials, scored by independent assessors blind to treatment condition, and used to assess such outcomes. Whether or not all forms of therapy aim for such outcomes, or researchers study them, they are clearly the outcomes desired by many people who seek psychotherapy. Perhaps this is why psychotherapists, irrespective of their own theoretical orientations, tend to choose psychodynamic psychotherapy for themselves (Norcross, 2005). Discussion One intent of this article was to provide an overview of some basic principles of psychodynamic therapy for readers who have not been exposed to them or who have not heard them presented by a contemporary practitioner who takes them seriously and uses them clinically. Another was to show that psychodynamic treatments have considerable empirical support.
The empirical literature on psychodynamic treatments does, however, have important limitations. First, the number of randomized controlled trials for other forms of psychotherapy, notably CBT, is considerably larger than that for psychodynamic therapy, perhaps by an order of magnitude. Many of these trials—specifically, the newer and better-designed trials—are more methodologically rigorous (although some of the newest psychodynamic randomized controlled trials, e.g., that of Clarkin et al., 2007, also meet the highest standards of methodological rigor). In too many cases, characteristics of patient samples have been too loosely specified, treatment methods have been inadequately specified and monitored, and control conditions have not been optimal (e.g., using wait-list controls or “treatment as usual” rather than active alternative treatments—a limitation that applies to research on empirically supported therapies more generally). These and other limitations of the psychodynamic research literature must be addressed by future research.
My intent is not to compare treatments or literatures but to review the existing empirical evidence supporting psychodynamic treatments and therapy processes, which is often underappreciated. In writing this article, I could not help being struck by a number of ironies. One is that academicians who dismiss psychodynamic approaches, sometimes in vehement tones, often do so in the name of science. Some advocate a science of psychology grounded exclusively in the experimental method. Yet the same experimental method yields findings that support both psychodynamic concepts (e.g., Westen, 1998) and treatments. In light of the accumulation of empirical findings, blanket assertions that psychodynamic approaches lack scientific support (e.g., Barlow & Durand, 2005; Crews, 1996; Kihlstrom, 1999) are no longer defensible. Presentations that equate psychoanalysis with dated concepts that last held currency in the psychoanalytic community in the early 20th century are similarly misleading; they are at best uninformed and at worst disingenuous.
A second irony is that relatively few clinical practitioners, including psychodynamic practitioners, are familiar with the research reviewed in this article. Many psychodynamic clinicians and educators seem ill-prepared to respond to challenges from evidence-oriented colleagues, students, utilization reviewers, or policymakers, despite the accumulation of high-quality empirical evidence supporting psychodynamic concepts and treatments. Just as antipsychoanalytic sentiment may have impeded dissemination of this research in academic circles, distrust of academic research methods may have impeded dissemination in psychoanalytic circles (see Bornstein, 2001). Such attitudes are changing, but they cannot change quickly enough. Researchers also share responsibility for this state of affairs (Shedler, 2006b). Many investigators take for granted that clinical practitioners are the intended consumers of clinical research (e.g., Task Force on Promotion and Dissemination of Psychological Procedures, 1995), but many of the psychotherapy outcome studies and meta-analyses reviewed for this article are clearly not written for practitioners.
On the contrary, they are densely complex and technical and often seem written primarily for other psychotherapy researchers—a case of one hand writing for the other. As an experienced research methodologist and psychometrician, I must admit that deciphering some of these articles required hours of study and more than a few consultations with colleagues who conduct and publish outcome research. I am unsure how the average knowledgeable clinical practitioner could navigate the thicket of specialized statistical methods, clinically unrepresentative samples, investigator allegiance effects, inconsistent methods of reporting results, and inconsistent findings across multiple outcome variables of uncertain clinical relevance. If clinical practitioners are indeed the intended “consumers” of psychotherapy research, then psychotherapy research needs to be more consumer relevant (Westen, Novotny, & Thompson-Brenner, 2005).
With the caveats noted above, the available evidence indicates that effect sizes for psychodynamic therapies are as large as those reported for other treatments that have been actively promoted as “empirically supported” and “evidence based.” It indicates that the (often unacknowledged) “active ingredients” of other therapies include techniques and processes that have long been core, centrally defining features of psychodynamic treatment. Finally, the evidence indicates that the benefits of psychodynamic treatment are lasting and not just transitory and appear to extend well beyond symptom remission. For many people, psychodynamic therapy may foster inner resources and capacities that allow richer, freer, and more fulfilling lives.
Table 2 Definition of Mental Health:
Items From the Shedler– Westen Assessment Procedure (SWAP–200; Shedler & Westen, 2007)
Is able to use his/her talents, abilities, and energy effectively and productively.
Enjoys challenges; takes pleasure in accomplishing things.
Is capable of sustaining a meaningful love relationship characterized by genuine intimacy and caring.
Finds meaning in belonging and contributing to a larger community (e.g., organization, church, neighborhood).
Is able to find meaning and fulfillment in guiding, mentoring, or nurturing others.
Is empathic; is sensitive and responsive to other people’s needs and feelings.
Is able to assert him/herself effectively and appropriately when necessary.
Appreciates and responds to humor.
Is capable of hearing information that is emotionally threatening (i.e., that challenges cherished beliefs, perceptions, and self- perceptions) and can use and benefit from it.
Appears to have come to terms with painful experiences from the past; has found meaning in and grown from such experiences.
Is articulate; can express self well in words.
Has an active and satisfying sex life.
Appears comfortable and at ease in social situations.
Generally finds contentment and happiness in life’s activities.
Tends to express affect appropriate in quality and intensity to the situation at hand.
Has the capacity to recognize alternative viewpoints, even in matters that stir up strong feelings.
Has moral and ethical standards and strives to live up to them.
Is creative; is able to see things or approach problems in novel ways.
Tends to be conscientious and responsible.
Tends to be energetic and outgoing.
Is psychologically insightful; is able to understand self and others in subtle and sophisticated ways.
Is able to find meaning and satisfaction in the pursuit of long-term goals and ambitions.
Is able to form close and lasting friendships characterized by mutual support and sharing of experiences.
The Idea That Wouldn't Die by Molly Knight Raskin Published on May 03, 2011 in Psychology Today
Just when you thought psychoanalysis had breathed its last, research resurrects and even validates certain core Freudian beliefs. Forget penis envy. Think conflicting motives and what talking to a shrink four days a week can do for you.
Gary Shteyngart has written three best-selling novels and been hailed by critics as one of today's most gifted young authors. But ask Shteyngart about his life a decade ago and he sums it up in two words: "major dysfunction."
Shteyngart was just 7 when his parents transplanted themselves from Leningrad (now St. Petersburg) to New York City. Theirs was the ever-better immigrant experience. Gary's was not. Quiet, frail, frequently bedridden with asthma, Shteyngart was sent to a Hebrew school where he was incessantly teased about his wardrobe (he had two shirts), his heavy accent, and his preference for Russian food. He had few friends, frequently worried about dying, and felt neither Russian nor American.
The isolation and alienation followed him to college in the midwest and back to New York, where he worked for tiny nonprofit organizations. Although Shteyngart was spending hours a day writing, he had a paralyzing fear of sharing his work with publishers. (His wildly comic first novel, The Russian Debutante's Handbook, was published only after he sent a portion of the manuscript to a fellow immigrant, who ran an MFA program in writing in New York; Shteyngart thought he was applying to the program, but his bowled-over friend sent the manuscript to his own publisher.) A series of "disastrous relationships" with women only fed his feelings of being a "second-class citizen."
And so Shteyngart, still in his 20s, embarked on a course of psychoanalysis. Although he was often depressed, there were no specific symptoms he sought to address. "I felt that my entire personality needed to be entirely re-examined and, when necessary, changed," Shteyngart says. "Other forms of therapy do not explore and rewire the personality to the same extent."
What attracted Shteyngart to psychoanalysis is precisely what has for more than a century made it fodder for impassioned, and often ugly, debate.
It is time-intensive and prohibitively expensive. Its benefits are not easy to measure, particularly compared with those promised by more popular, contemporary methods of treatment like cognitive behavioral therapy (CBT). As a result, psychoanalysis has been dropped from the curriculum of many medical schools and is rarely covered by insurance plans. When it is taught and practiced, experts say, modern psychoanalysis, also called psychodynamic psychotherapy, often bears little resemblance to the treatment put forward by its founding father, Sigmund Freud.
But psychoanalysis is a profound exploration of human subjectivity—our inner world with all its memories and desires and impulses—and its relation to the external, objective world. And it is much more than a treatment. It's also a set of theories about the nature of human experience, its depth and complexity. "Analysis is the most elaborate and nuanced view of the mind that we have," Nobel-winning neuroscientist Eric Kandel recently told a meeting of the American Psychoana-lytic Association.
At its center is the belief that subjectivity matters, that regardless of how many millions of circuits science shows are carrying out the work of the brain without our awareness, we still experience a unified sense of self that gives our lives coherence and meaning. In this regard, experts argue, psychoanalysis, which celebrates its hundredth anniversary in America this year, is very much alive.
"Psychoanalysis reflects decades and decades of thinking about and pondering on the nature of the human mind," says Peter Fonagy, Freud chair in psychiatry at University College London and director of the London-based Anna Freud Center. "We've identified the core constructs within psychoanalysis as a theory"—the nature of consciousness, the role of early childhood in shaping understanding and behavior, the effect of unconscious processes on everyday life, to name a few—"and shown that they continue to advance our understanding of the human mind. In this sense, I think psychoanalysis is in the best shape it's ever been in."
Fonagy and other long-time psychoanalysts credit the staying power of psychoanalysis in part to a culture shift among their colleagues. For most of the 20th century, psychoanalysis became a guru science, driven by cults of personality around Freud and other dominant figures rather than by scientific investigation.
Many analysts were spinning out theories about the mind without gathering evidence to support them—say, the idea that all our thoughts and actions are driven by only two basic motives, sex and aggression—and doing little to disseminate them outside their own exclusive circles. One result was the creation of factions and intense infighting within them over details that had no currency in the wider world of psychiatry.
"There were prejudices built into psychoanalysis that really hurt it," says Mark Solms, head of neuropsychology at the University of Cape Town, South Africa, and a practicing psychoanalyst. "Many psychoanalysts felt they didn't want to reduce what they did to numbers, that their work was about the soul. So when other sciences were advancing with research, psychoanalysis didn't. They essentially shut their eyes and said 'we don't do that.' And that only reinforced the caricature" of a field that was old-fashioned, spoke largely to itself, and was obsessed with sex.
The shift of mainstream psychiatry to psychotropic medication and the development of short-term therapies—beginning in the late 1950s and accelerating through the 1990s—eventually jolted psychoanalysts into the realization that they had to subject their grand theories to rigorous testing. Today, scientists are working to build a body of empirical research to support the efficacy of psychoanalysis, a tough task for a treatment that often takes years and hundreds of sessions.
Unlike its therapeutic rival CBT, psychoanalysis does not lend itself to easy-to-measure evidence like the speedy elimination of symptoms. But a growing body of research—including neuroscientific interest in the nature of consciousness—has helped bring psychoanalysis to a new place at the psychiatric table.
Jonathan Shedler, an associate professor of psychiatry at the University of Colorado School of Science, has examined the efficacy of psychodynamic therapy—a term describing treatment based on psychoanalytic theory and methods but briefer and less intensive—for everything from depression and anxiety to panic disorders, personality disorders, and substance abuse. He has found that the benefits of psychodynamic therapy extend well beyond symptom relief.
"The benefits of newer therapies often start to decay after treatment ends," Shedler contends. "Studies of psycho-dynamic therapies show that people not only look much better in terms of symptom relief, personality functioning, and social functioning after treatment, but they stay better. What's more, they display continued improvement."
Insights gained in analysis appear to beget psychological skills that grow stronger with use; patients are able to think and reflect more productively, says Shedler. Among patients with borderline personality disorder—a condition notoriously resistant to treatment—only 13 percent still met the diagnostic criteria for the disorder five years after completing psycho-dynamic therapy compared with 87 percent who underwent other forms of treatment.
To those familiar with traditional psychoanalysis, there's no small irony in the idea that it has lacked the science to support it. Before he invented psychoanalysis, Freud was a neuroscientist, and while he didn't have available to him the technology to explore the brain, he believed his theories about the mind had to be rooted in biology. "Freud recognized that you need to bring the subjective side of nature into science," says Solms, a pioneer in the field of neuropsychology.
Today, however, science provides technology to explore some of the most fundamental questions posed by psychoanalysis, such as the very structure of the psyche. And while there is still a large gap between what brain scans reveal and what happens in treatment, the research is proving the validity of many tenets of psychoanalysis, both theory and treatment. Through the use of functional magnetic resonance imaging, for example, neuroscientists have found that many operations of the psyche take place in widely disbursed neural circuits. Specifically, such mental functions as passion, reason, and conscience are activated in different areas of the brain. The finding supports Freud's contention that the psyche can be differentiated into id, ego, and superego.
"We've confirmed one of the central premises of psychoanalysis," says Shedler. "That is, we have different brain structures that operate at the same time but respond in very different ways to information. One result is that the mind is often in conflict, and we experience contradictory motives."
Shedler points to the basal ganglia, situated at the base of the forebrain and driven by rapid emotions, and the prefrontal cortex, which houses our capacity for logic and reasoning. When both are active, we might experience a deep visceral fear, even though we're not aware of any imminent danger. Or we might feel the desire for an intimate relationship while at the same time fearing intimacy.
Neuroscience has also confirmed another fundamental tenet of psychoanalytic theory—the idea that our motivations are largely unconscious, and that our brains have active repressive mechanisms that protect us from disturbing thoughts and impulses. "Neuroscience tells us unambiguously that consciousness really is just the tip of the iceberg," says Shedler.
Ask a psychoanalyst which theories have proven most enduring over a century of research, science, and clinical practice, and you're likely to hear it's the theory of the unconscious. Freud put forth the idea that there are three levels of consciousness: the conscious part of the mind of which we are aware and about which we can verbalize; the preconscious, consisting of all the memories and thoughts that, with effort, can be brought into conscious awareness; and the unconscious, the part of the mind that is not accessible to us and which houses some of the most intense urges, feelings, and desires that drive us.
"We now know that most of the mind is unconscious, and that it's complex," says Robert Michels, a university professor of medicine and psychiatry at Cornell University, formerly dean of its medical school, and supervising psychoanalyst at Columbia University. "That's the basic stance of psychoanalysis, and it's absolutely spot-on."
Psychoanalysis has special relevance in today's wired world, contends Todd Essig, a training and supervising psychoanalyst at the William Alanson White Institute in New York. We're not humanly equipped to shut out the technologies of connection offering us a steady stream of distraction and providing constant feedback and reinforcement.
Technology is not going away, says Essig, but it can leave us feeling distracted, overstimulated, hollowed out, and alienated. "Psychoanalysis is one way to recapture the important piece of life that is being leached out of our experience. While technology compels us to live in a constant present, psychoanalysis connects us with memory, the past, and desire, what we want next. It stretches the existential muscles that are atrophying when we spend too much time with our Blackberries." For Essig, the corrective to passing our days in the ever-connected moment is not less technology but more life, including more inner life.
Essig points to one of his patients, a music industry hipster, who begins and ends each session by making a show of checking his iPhone for messages and offering up a report on his latest Twitter followers. At first, Essig thought that the patient's ritual of checking was a show of importance. But by exploring the patient's need to be constantly connected, he understood the man was letting him know he was releasing himself from being trapped in the present tense of stimulation to enter a more reflective state.
Dreams are another domain in which ongoing research supports many ideas that originated in psychoanalytic theory. For sure, modern scientific studies of the brain have led to some contradictory theories about dreaming—that dreams mean little, that dreams mean something (if only we could figure out what), that they represent strategies of rehearsal for events that matter, and much more.
In the 1960s and '70s, scientists learned that dreams occur involuntarily but regularly—about five or six times, of increasing duration, throughout the night—while the brain is aroused physiologically but the body is immobilized physically. The discovery of dream sleep, distinguished by the presence of rapid eye movements, contributed to the discrediting of psychoanalysis. Dreams, it seemed clear, were the product of a revved-up brain—not, as Freud believed, a reflection of hidden or frustrated desires, especially those of a sexual or aggressive nature.
But studies conducted in the 1990s, using imaging technology to examine neural activity in the dreaming brain, corroborate some ideas Freud laid out in The Interpretation of Dreams. During dream states, certain circuits of the brain—notably those based in rational thought and reality—are inactive. The neural circuits that remain active while we dream, however, are those governing emotions, sensations, and memories. While much remains to be discovered about the dreaming brain, the neuroscientific evidence suggests that there's a close link between the content of our dreams and our deepest instinctual drives.
"Dreams are not froth," says Solms. "They're a valid mental construction under which lies the core of what we really want out of life." What Freud observed makes sense, he adds: "If you take it as fact that we have this desire system in our brains that drives our dreams, then there's every reason to believe that if you explore your dreams you can learn something valuable about yourself."
While contemporary psychoanalysts interpret the desires underlying dreams much more broadly and far less rigidly than earlier generations did, they still borrow early techniques in analyzing dreams. They ask patients to recall their dreams in detail and say whatever comes to mind as they do. Solms notes that by taking the time to recall the content of a dream, it's the patient—not the analyst—who almost always discovers the desire that underlies it.
"We don't say 'Mr. or Mrs. Jones, your dream means this,'" Solms says. "Instead, patients figure it out themselves. When you take the time to deconstruct a dream, it just makes sense."
Why bother to make sense of dreams—particularly those that seem too fantastical or bizarre to have any obvious value? Precisely because dreams are vivid, uncensored representations of our desires and fears, they can be a window into what we really want out of life, Solms insists.
Another theory that vies for a spot among the most enduring legacies of psychoanalysis concerns the importance of experiences in early childhood. The understanding that our past influences who we are today, and especially that the first few years of childhood have a profound influence on all our development, informs almost all types of contemporary therapy.
It might sound obvious, but the view that early development creates an enduring template that stamps behavior and feelings throughout life can be credited to classic psychoanalysis. Researchers now know that early experiences of care literally shape the developing nervous system and play out in the nature and quality of emotional attachments we form decades later. Neuroscience has shown that personal experience is so powerful it even influences whether or not specific genes get expressed, including those determining responsiveness of nerve cells to various neurohormones.
Encouraging adults to talk about their early life and relationships, particularly with caregivers, can provide tremendous insight into current psychological problems, says Peter Fonagy. "This, to me, is the great triumph of the last century of psychoanalysis," he adds. "It can completely alter people's experience of culture and childhood."
Exploring our personal narrative—the modus operandi of psychoanalysis, the therapy—helps us to understand why we do what we do. Finding meaning in certain behaviors (which help or harm us) is a valuable step in summoning the wherewithal to change them.
Of course, no conversation about psychoanalysis is complete without discussion of transference. Freud defined it as an unconscious phenomenon that influences the relationship between patient and therapist, occurring when a patient shifts onto a therapist feelings about family or friends experienced earlier in life.
But the idea has since grown into a more general theory of behavior. Without being aware of doing so, we all constantly transfer feelings about significant figures in our lives onto those with whom we currently interact. It seems to be one of the mind's prevailing heuristics.
"Transference can cause a tremendous amount of suffering," says Glen Gabbard, professor of psychiatry and psychoanalysis at Baylor College of Medicine and director of the Baylor Psychiatry Clinic. "It's like having a movie projector in your head that plays out the relationship you had with someone in your past onto the face of someone else. This can lead you to assume someone is thinking something they are not or to expect them to act in specific ways."
In psychoanalysis, exploring the emotions at play between patient and therapist remains central to successful treatment, Gabbard points out. Identifying patterns within the therapeutic relationship helps patients identify the dynamics of self-defeating relationships outside of treatment and gives them the skills to change such patterns.
Despite the enduring value of some key psychoanalytic concepts, psychoanalysis has no shortage of hurdles to overcome if it is to remain a viable therapeutic option. Chief among them is health insurance. The vast majority of insurance companies do not cover the cost of psychoanalysis—practitioners often recommend a course of three or more sessions a week to keep the process intense and deep and to maintain access to core problems—relegating it to those who can afford upwards of $150 an hour or who are able to negotiate a lower fee with their analyst. Then there's time; most working professionals don't have several hours a week to devote to therapy. Finally, there's the tantalizing promise of relief that other, shorter forms of the therapy offer, to say nothing of the ease of pharmaceutical bliss, for the speedy elimination of distressing symptoms.
But those who remain at the forefront of psychoanalysis are not sounding any alarm bells just yet. They contend that the complexity of the mind assures that no single perspective can capture the whole truth of the human experience. And there will always be a place for psychoanalysis. It might remain beleaguered as a treatment, but it will always offer value in making sense of the messy reality of mental life.
"Maybe we will lose psychoanalysis as a traditional institution," Fonagy says. "If that happens, I'd say good-bye and good riddance. As long as the core tenets of psychoanalysis remain, that's all that matters. And I am confident they will."
Not Your Parents' Psychoanalysis
If there's one fact about psychoanalysis that practitioners wish could permeate the national conscious, it's this: The methods of most modern day psychoanalysts have evolved significantly since the time of Sigmund Freud.
Despite the prevailing caricatures, psychoanalysis today is not all about sex. And you can be quite certain you don't have an Oedipal complex or penis envy. Nor is your shrink likely to light up a cigar and wait expectantly as you lie on a stiff couch and struggle for something to say.
Psychodynamic psychotherapy, as it's known today, takes a much less doctrinaire approach to treatment than it once did. "Psychoanalytic therapists are warm, interested, and curious to find out about the causes of a person's suffering," says Nancy McWilliams, a visiting professor at Rutgers University's Graduate School of Applied and Professional Psychology. "People come to therapists for very complex emotional experiences that do not usually translate into categories, and I think the best language we have for addressing them is still that of psychoanalysis."
McWilliams adds: "At its core, psychoanalysis is an openness to another human's experience. It can suit almost anybody."
Take the case of David Weiss. A New York-based writer who covers the music industry, Weiss says his interest in psychoanalysis grew out of a "classic combination of issues" including sex, substances, and his mother. Weiss, 38, says he was fortunate to find an analyst who made analysis affordable for him.
Including travel time, Weiss dedicates approximately 16 hours a month to psychoanalysis, an experience he chronicles in his PT blog, Mr. Analysand. Weiss considers his analyst contemporary in many ways. She does not consign him to a couch (although he once decided to try it out and found reclining to be too isolating and that he much preferred looking his analyst in the eye). She is not silent or dispassionate, and sometimes talks for an entire session. What's more, Weiss says his analyst is young, friendly, and listens to him in "a highly-trained, special way."
"There are aspects of psychoanalysis that are immovable," says Peter Fonagy, Freud chair in psychiatry at University College London and director of the London-based Anna Freud Center. "But there are also many aspects that can be played with. We are not all rigid in the way we treat people; we work with people to find a method that works for them."
Some contemporary analysts sit directly facing their patients, instead of perching outside the patient's line of vision. Today's psychoanalysts do not use silence to encourage patients to freely associate, and they do make suggestions to patients, ones that are neutral, but potentially helpful—such as pointing out when a patient is actively avoiding a topic that might be distressing. And while many psychoanalysts prefer to see patients several times a week to maintain the intensity that is a hallmark of their approach, there are no rules as to what schedule constitutes successful treatment.
"If you've been stuck in the same place in life for a while and can't get out, then treatment might require more time and deeper scrutiny," Fonagy suggests. "But if a psychoanalyst tried to persuade you that you need five-times-a-week analysis for five years, you should run a mile."
And whether or not they are willing to admit it, many contemporary psychoanalysts borrow from an array of therapies, including cognitive behavioral therapy, and vice versa.
"Psychoanalysts are coming around to the idea that you don't always have to get to the navel of the problem to solve it," says Fonagy. "Some people can be helped without having to dig up the entire root."
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