The scientific standing of Psychoanalysis
University of Cape Town, South Africa;
Conflicts of interest. None.
This paper summarises the core scientific claims of psychoanalysis and rebuts the prejudice that it is not ‘evidence-based’. I address the following questions.
(A) How does the emotional mind work, in health and disease?
(B) Therefore, what does psychoanalytic treatment aim to achieve?
(C) How effective is it?
© The Author 2018. This is an Open Access article, distributed under the terms of the Creative Commons Attribution- NonCommercial-NoDerivatives licence (http://creativecommons. org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the ori- ginal work is unaltered and is properly cited. The written per- mission of Cambridge University Press must be obtained for com- mercial re-use or in order to cre- ate a derivative work.
As regards the workings of the emotional mind, our three core claims are the following.
(1) The human infant is not a blank slate; like all other species, we are born with innate needs. These needs (‘demands upon the mind to perform work’, as Freud called them, his ‘id’) are felt and expressed as emotions. The basic emotions trigger instinctual behaviours, which are innate action plans that we perform in order to meet our needs (e.g. cry, search, freeze, flee, attack). Universal agreement about the number of innate needs in the human brain has not been achieved, but mainstream taxonomies (e.g. Panksepp, 1998) include the following.1
- We need to engage with the world – since all our biological appetites (includ- ing bodily needs) can only be met there. This is a foraging or seeking or ‘wanting’ instinct. It is felt as interest, curiosity and the like. (It coincides roughly but not completely with Freud’s concept of ‘libido’.)
- We need to find sexual partners. This is felt as lust. This instinct is sexually dimorphic (on average) but male and female inclinations exist in both genders.
- We need to escape dangerous situations. This is fear.
- We need to destroy frustrating objects (things that get between us and satisfac- tion of our needs). This is rage.
- We need to attach to caregivers (those who look after us). Separation from attachment figures is felt not as fear but as panic, and loss of them is felt as despair. (The whole of ‘attachment the- ory’ relates to vicissitudes of this need.)
- We need to care for and nurture others, especially our offspring. This is the so-called ‘maternal instinct’, but it exists (to varying degrees) in both genders.
- We need to play. This is not as frivolous as it appears; play is the medium through which social hierarchies are formed (‘pecking order’) and in-group and out-group boundaries maintained.
The (upper brain-stem and limbic) anat- omy and chemistry of the basic emotions is well understood (see Panksepp, 1998 for a review).
The main task of mental development is to learn how to meet our needs in the world. We do not learn for its own sake; we do so in order to establish optimal action plans to meet our needs in a given environment. (This is what Freud called ‘ego’ development.) This is necessary because innate action pro- grammes have to be reconciled with actual experiences. Evolution predicts how we should behave in, say, dangerous situa- tions, but it cannot predict all possible dan- gers (e.g. electrical sockets); each individual has to learn what to fear. This typically happens during critical periods in early childhood, when we are not best equipped to deal with the fact that innate action plans often conflict with one another (e.g. attachment v. rage, curiosity v. fear). We therefore need to learn compromises, and we must find indirect ways of meeting our needs. This often involves substitute-
1Here I am focusing on emo- tional needs – which are felt as separation distress, rage, etc. – not bodily drives – which are felt as hunger, thirst, etc. – or sen- sory affects – which are felt as pain, disgust, etc. (See Panksepp, 1998.) The way in which I use the term ‘action plans’ in this article is synonymous with the use of the term ‘predictions’ in contemporary computational neuroscience.
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formation (e.g. kicking the cat). Humans also have a large (cortico-thalamic) capacity for satisfying their needs in imaginary and symbolic ways. It is crucial to recognise that successful action programmes entail successful emotion regulation, and vice versa. This is because our needs are felt as emotions; thus, successful avoidance of attack reduces fear, successful reunion after separation reduces panic, etc., whereas unsuccessful attempts result in persistence of fear and panic, etc.
(3) Most of our action plans (i.e. ways of meeting our needs) are executed unconsciously.
Consciousness (‘working memory’) is an extremely limited resource, so there is enormous pressure to consolidate and automatise learned solutions to life’s pro- blems (for a review see Bargh & Chartrand, 1999, who conclude that only 5% of our goal-directed actions are con- scious). Innate action programmes are effected automatically from the outset, as are the programmes acquired in the first years of life, before the cortical (‘declara- tive’) memory systems mature. Multiple unconscious (‘non-declarative’) memory systems exist, such as ‘procedural’ and ‘emotional’ memory (which are mainly encoded at the level of the basal ganglia). These operate according to different rules. Not only successful action plans are auto- matised. With this simple observation, we can do away with the unfortunate distinc- tion between the ‘cognitive’ and ‘dynamic’ unconscious. Sometimes a child has to make the best of a bad job in order to focus on the problems which it can solve. Such illegitimately or prematurely automa- tised action programmes are called ‘the repressed’. In order for automatised pro- grammes to be revised and updated, they need to be ‘reconsolidated’ (Tronson & Taylor, 2007); that is, they need to enter con- sciousness again, in order for the long-term traces to become labile once more. This is difficult to achieve, not least because most procedural memories are ‘hard to learn and hard to forget’ and some emotional memories – which can be acquired through just a single exposure – appear to be indel- ible, but also because the essential mechanism of repression entails resistance to reconsolidation of automatised solutions to our insoluble pro- blems. The theory of reconsolidation is very important for understanding the mechanism of psychoanalysis.
The clinical methods that psychoanalysts use flow from the above claims.
(1) Psychological patients suffer mainly from feelings. The essential difference between
psychoanalytic and psychopharmacological methods of treatment is that we believe feel- ings mean something. Specifically, feelings represent unsatisfied needs. (Thus, a patient suf- fering from panic is afraid of losing some- thing, a patient suffering from rage is frustrated by something, etc.) This truism applies regardless of aetiological factors; even if one person is constitutionally more fearful, say, than the next, their fear is still meaningful. To be clear: emotional disorders entail unsuccessful attempts to satisfy needs.
(2) The main purpose of psychological treat- ment, then, is to help patients learn better (more effective) ways of meeting their needs. This, in turn, leads to better emotion regulation. The psychopharmacological approach, by contrast, suppresses unwanted feelings. We do not believe that drugs which suppress feelings can cure emotional disorders. Drugs are symptomatic treatments. To cure an emotional disorder, the patient’s failure to meet their underlying need(s) must be addressed, since this is what is causing their symptoms. However, symptom relief is sometimes necessary before patients become amenable to psy- chological treatment, since most forms of psychotherapy require collaborative work between patient and therapist. It is also true that some types of psychopathology never become accessible to collaborative psychotherapy.
(3) Psychoanalytical therapy differs from other forms of psychotherapy in that it aims to change deeply automatised action plans. This is necessary for the reasons outlined above. Psychoanalytic technique therefore focuses on the following.
• Identifying the dominant emotions (which are consciously felt but not necessarily recognised as belonging to the self, etc.).
• These emotions reveal the meaning of the symptom. That is, they lead the way to the (ineffective) automatised pro- grammes that gave rise to the feelings.
• The pathogenic action programmes cannot be remembered directly for the very reason that they are automatised (i.e. unconscious). Therefore, the analyst identifies them indirectly, by bringing to awareness the repetitive patterns of behav- iour derived from them.
• Reconsolidation is thus achieved through reactivation of mainly subcortical long- term traces via their derivatives in the pre- sent situation (this is called ‘transference’ interpretation). Only cortical memories can be ‘declared’.
• Such reconsolidation is nevertheless dif- ficult to achieve, mainly owing to the ways in which non-declarative memory sys- tems work, but also because repression entails resistance to the reactivation of
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insoluble problems. For these reasons, psychoanalytic treatment takes time – i. e. numerous and frequent sessions – to facilitate ‘working through’.
Mental healthcare funders need to learn how learning works. For a more detailed account of the mechanism of psychoana- lytic therapy, see Solms (2017).
Psychoanalytic therapy achieves good outcomes – at least as good as, and in some respects better than, other evidence-based treatments in psych- iatry today.
(1) Psychotherapy in general is a highly effective form of treatment. Meta-analyses of psycho- therapy outcome studies typically reveal effect sizes of between 0.73 and 0.85. An effect size of 0.8 is considered large in psy- chiatric research, 0.5 is considered moder- ate, and 0.2 is considered small. To put the efficacy of psychotherapy into perspec- tive, recent antidepressant medications achieve effect sizes of between 0.24 and 0.31 (Kirsch et al, 2008; Turner et al, 2008). The changes brought about by psy- chotherapy, no less than drug therapy, are of course visualisable with brain imaging.
(2) Psychoanalytic psychotherapy is equally effective as other forms of evidence-based psycho- therapy (e.g. cognitive–behavioural therapy (CBT)). This is now unequivocally estab- lished (Steinert et al, 2017). Moreover, there is evidence to suggest that the effects of psychoanalytic therapy last longer – and even increase – after the end of the treat- ment. Shedler’s (2010) authoritative review of all randomised controlled trials to date reported effect sizes of between 0.78 and 1.46, even for diluted and truncated forms of psychoanalytic therapy. An especially methodologically rigorous meta-analysis (Abbass et al, 2006) yielded an overall effect of 0.97 for general symptom improvement with psychoanalytic therapy. The effect increased to 1.51 when the patients were assessed at follow-up. A more recent meta-analysis by Abbass et al (2014) yielded an overall effect size of 0.71, and the finding of maintained and increased effects at follow-up was reconfirmed. This was for short-term psychoanalytic treatment. According to the meta-analysis of de Maat et al (2009), which was less methodologically rigorous than the Abbass studies, longer- term psychoanalytic psychotherapy yields an effect size of 0.78 at termination and 0.94 at follow-up, and psychoanalysis proper achieves a mean effect of 0.87, and 1.18 at follow-up. This is the overall finding; the effect size for symptom improvement (as opposed to personality change) was 1.03 for long-term psychoanalytic therapy, and for
psychoanalysis it was 1.38. Leuzinger- Bohleber et al (2018) will shortly report even greater effect sizes for psychoanalysis in depression. The consistent trend toward larger effect sizes at follow-up suggests that psychoanalytic therapy sets in motion pro- cesses of change that continue after therapy has ended (whereas the effects of other forms of psychotherapy, such as CBT, tend to decay).
The therapeutic techniques that predict the best treatment outcomes, regardless of the form of psychotherapy, make good sense in relation to the psychodynamic mechanisms out- lined above. These techniques include (Blagys & Hilsenroth, 2000):
- unstructured, open-ended dialogue between patient and therapist
- identifying recurring themes in the patient’s experience
- linking the patient’s feelings and percep- tions to past experiences
- drawing attention to feelings regarded by the patient as unacceptable
- pointing out ways in which the patient avoids such feelings
- focusing on the here-and-now therapy relationship
- drawing connections between the ther- apy relationship and other relationships.
It is highly instructive to note that these techniques lead to the best treatment out- comes regardless of the type of psychother- apy the clinician espouses. In other words, these same techniques (or at least a subset of them; see Hayes et al, 1996) predict opti- mal treatment outcomes in CBT too, even if the therapist believes they are doing something else.
It is therefore perhaps not surprising that psychotherapists, irrespective of their sta- ted orientation, tend to choose psychoana- lytic psychotherapy for themselves! (Norcross, 2005)
I am aware that the claims I have summarised here do not do justice to the full complexity and variety of views in psychoanalysis, both as a theory and a therapy. I am saying only that these are our core claims, which underpin all the details, includ- ing those upon which we are yet to reach agree- ment. These claims are eminently defensible in the light of current scientific evidence, and they make simple good sense.
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