For and against psychoanalysis

Freud’s couch

One of the biggest debates in psychology is that between the psychodynamic school of thought and the cognitive behavioural school. I remember as an undergraduate participating in just such a debate and arguing for the CBT side. Unfortunately the other debater on my side didn’t consult with me beforehand and used her speech to attack Freud for all the reasons that people usually criticize him. She said he was sex-obsessed and addicted to cocaine. I was trying to put forward a more nuanced position, that while the psychodynamic school has a lot to offer, the CBT proponents are more relevant and focused on the present rather than the past. It was not that I strongly believed in this position but I was interested to debate the merits of both forms of psychotherapy.

Which brings me to the 44th Maudsley debate held quite recently at University College London. Peter Fonagy and Allessandra Lemma were in favour of the motion that “psychoanalysis has a valuable place in modern mental health services” while Paul Salkovskis and Lewis Wolpert were against.

Here’s the summary from the University College London website:

The debate opened with a striking majority in favour of psychoanalysis with 251 pro the motion, 36 abstainers and 44 against.

Prof. Peter Fonagy reviewed the evidence base for psychotherapies, noting that psychodynamic therapies fared no worse than CBT. He emphasised the convergence of psychodynamic and neuroscientific accounts of development.

Opposing the motion, Prof. Paul Salkovskis likened psychoanalytic schools to cults, criticised the absence of a symptom-based approach and some of the theories underpinning psychoanalysis.

Prof. Alessandra Lemma drew on her experience in psychoanalysis and CBT to argue for an eclectic approach, but argued that psychoanalysis provides an unrivalled framework for understanding interactional processes.

Prof Lewis Wolpert shared his personal negative experience with psychoanalysis when suffering from severe depression, and described it as a pseudoscience with no evidence to back it up. He also accused his opponents of conflating psychodynamic therapies with psychoanalysis.

It closed with 260 in favour of the motion, 33 abstainers and 38 against.

Listening to a podcast of the debate, I was struck initially by how the two sides seemed to be debating different things. Fonagy and Lemma argued for the value of psychodynamic psychotherapies while Salkovskis and Wolpert focused their attack on the practice of psychoanalysis itself.

As a psychologist with several years of experience I realized that I was still not entirely sure what psychoanalysis is and how it differs from psychodynamic psychotherapy. I had an idea that psychoanalysis involves four sessions a week on the couch with a trained analyst and that this goes on for a few years. Psychodynamic therapy by contrast usually involves once or twice weekly sessions and the client and therapist sit facing each other in comfortable chairs. I’ve always thought that this was a better way of doing therapy than lying down with the psychotherapist sitting behind you. Just because Freud practiced in this way doesn’t mean that this is the way that therapy should be done. Analysis also seemed to me to be a much harsher and less friendly way of doing therapy since there is less interaction and the analyst is not encouraged to bring their subjectivity to the therapy. Of course this is all just what I’ve read or heard and so I was hoping to be a bit more enlightened by this debate.

Well no. As I said, Fonagy and Lemma argued, very convincingly I thought, that psychodynamic therapy has a valuable role in modern mental health services while the other two raised some valuable points about the problems with classic psychoanalysis. In the general discussion that followed, members of the audience commented that they would like to see a greater dialogue between psychodynamic therapies and CBT. I’m aware of two examples of how both sides have incorporated methods and insights from the other. Psychodynamic therapists do challenge irrational beliefs and thoughts while CBT therapists at times try and uncover deep-seated (or unconscious) beliefs about the self (called schemas).

I was disappointed that Fonagy and Lemma didn’t address the perceived shortcomings of the practice of psychoanalysis itself but I can also see why they would consciously choose not to. At a time when the NHS is cutting back on psychodynamic psychotherapies (and other therapies), it would be foolish to provide any ammunition for this. But I suspect that many psychodynamically-oriented psychologists are slightly suspicious of the apparently elite psychoanalytic guilds. Within the psychodynamic school, those who can claim to be analysts are afforded greater respect (it seems) and sometimes appear to speak with more authority.

Moving to the broader issue of psychoanalysis as a body of knowledge and a theory of human motivation, behaviour and personality development, this has been invaluable in many disciplines and not just psychotherapy. As Lemma put it, psychoanalysis offers us a way of understanding personal interactions which is unrivalled by any other theory.

But I still find it rather intimidating to be confronted with the weight of psychoanalytic thought. Just researching this post, for example, I found an essay on Lacan and realised that I know almost nothing about him. Perhaps I need to do a “Lacan for beginners” post in order to educate myself.

But I’m also interested in broader debates around psychoanalysis and psychodynamic therapies and interventions. In South Africa we don’t even have a national health system and so psychotherapy is often out of reach of the majority of the population. There are also issues of elitism when we compare clinical psychology, counselling psychology, community psychology and social work. I certainly see the value of a clinical training and one that encompasses psychodynamic training. But even that is no guarantee that the therapy will be a good one.

I certainly came away from the debate with my belief in an eclectic approach intact. The only trouble with this is that an eclectic approach can be rather unfocused. But if being eclectic means being flexible enough to respond to the needs of our clients, then I’m all for it.

Breaking up with your therapist is also hard to do

Breaking up, as Neil Sedaka sings it, is hard to do. Equally so with your therapist, as I discovered on Wednesday. I felt pretty angry afterwards, which is a good sign that the therapist was not supporting where I was coming from. At one point I told him, “Stuff you!” What I should have said was: “Shut the f… up, this is my session and you’re doing all the talking.” Now I’m bit embarrassed about the ‘Stuff you’ part but he was giving this whole speech without any regard for how it was coming across. I managed to put my side of the story (quite well I thought) but his blunt interpretations have also given me food for thought. Maybe he’s actually partly right, I realised today. Still, he’s a bully and an ass.

Now I hope the slightly flippant tone of this post doesn’t make you think that I’m taking this whole break-up thing lightly. Far from it. But I also think that we need to be able to laugh about the stuff that’s the most painful to us. After all, choosing your partner is probably the biggest decision of your life so there deserves to be a lot of agonising over it, right?

Coming back to the therapy break-up, I was interested to read other people’s experiences. In the NYT, Richard Friedman says:

With rare exceptions, the ultimate aim of all good psychotherapists is, well, to make themselves obsolete. After all, whatever drove you to therapy in the first place — depression, anxiety, relationship problems, you name it — the common goal of treatment is to feel and function better independent of your therapist.
To put it bluntly, good therapy is supposed to come to an end.

But when? And how is the patient to know? Is the criterion for termination “cure” or is it just feeling well enough to be able to call it a day and live with the inevitable limitations and problems we all have?

The likeable Dr Rob over at shrinktalk adds the following:

… some clients are not connecting with their therapist or are not making progress that is to their satisfaction. No therapist can work perfectly with every client , and good therapists understand this. Again, honesty is the best policy here, and simply telling your therapist that you would like to work with someone else is completely acceptable. However, some clients struggle with this, and will often leave me voicemails with specious reasons so as not to deal with perceived confrontation:

I’m cured
My insurance won’t cover it
It’s too expensive
Your office is too far away
It’s too cold out
…
You are too young
You are too old
You are incompetent (commonly relayed as “you suck,” or “you’re an arrogant ass”)
I want to work with someone with blond hair
I need a Jewish therapist
Fuck off and die

Now I know he’s just joking about the “fuck off and die” part but it feels quite therapeutic just to read that and imagine someone saying it to their therapist via voicemail. Of course, as Rob also points out, very often clients leave therapy because the therapy is touching a nerve and it’s uncomfortable for them to go there.

For me, the answer was yes and no. Yes, we were touching a nerve and no, I wasn’t running away from it as much as getting frustrated that he wasn’t helping me to make progress in working with it. Just let me be, I wanted to say, let me do this therapy at my pace. And it also didn’t help that he was trying to pressure me into making a longer commitment to the therapy. Ambivalence is not a healthy state to be in, was the message I got, so you need to commit to the process. Now I agree that it’s not that helpful to be ambivalent but it’s also not helpful to ignore the ambivalence by rushing into a commitment. That way leads to resentment. What I think he should have done was to try and hold the ambivalence and try and be sensitive to the underlying anxiety rather than trying to bully me into doing things his way.

From a reader’s point of view I enjoyed some of the comments over at Yelp:

Take him/her out to dinner, get a couple of drinks going, and say, “It’s not you, it’s me.” Leave him/her with the check and SCRAM.

If it’s not working for you, be up front with him/her. Try to identify what it is that you are looking to work on and why that’s not happening. Maybe you’ve gone as far as you can go with this particular practicioner. You won’t know until you vocalize your concerns. … Sometimes it’s just time to move on.

As for the song, I like the Violent Femmes version.

Turning the therapeutic tables

On the way out the door, a client starts grilling me:

“Do you have kids? Are you married?”
“No, not yet. We’ll get there one day.”
“But you’re still young. How old are you?”
“I’m old already. I’m 38.”
“Oh well, you live your life the way you want,” she says, delivered with an airy flourish.
Oh great, I think. Another patient who thinks I’m gay.

Remembering this exchange today, I can’t help chuckling at my client’s curiosity. And it also gets me thinking about psychology and power. I often think that psychologists love being the ones asking the questions rather than receiving them. One psychologist I knew always answered a question with another one. [A handy tip: So what makes you think that?] It’s not so great when we’re on the receiving end of prying. Put another way, we like to be the ones wielding the power, putting the patient under the microscope and analysis. Analysis after all comes from the Greek work “analyein” which means “to break up”. The dictionary gives as one definition: “The abstract separation of a whole into its constituent parts in order to study the parts and their relations.”

He loves me then he loves me not.

So what do we (as therapists) do when it is the client who wants to break us up into little bits and to study our parts and relations? Well, we tend to become a bit defensive. We devise useful ways of deflecting the question such as: “We can talk about me if you like, but I’m wondering what that’s about for you. Are you wondering if you can trust me, if I will understand where you’re coming from?”

No, I was just curious.
What were you thinking?
No, I just wanted to know. You don’t have to answer the question if you don’t want to.

I envisage the conversation going round and round until the therapist answers or deflects the question successfully. In my own therapy, I have found it liberating to be able to discuss my reservations about the therapeutic relationship. Having inside knowledge about the process helps but also hinders here since I know it’s a bit of a game on my part. Trying to outsmart my therapist by making shrewd interpretations. I am quite restrained in telling my current shrink why it’s just not working for me and the poor man has to sit through at least another three sessions of this before I break up with him. He is at least getting a decent fee for it but it is also a bit disconcerting sitting there and talking about how he just doesn’t quite “get” me.

Most South African men I know are just not that sensitive, I tell him, so you’re starting from a difficult position. I also have a natural suspicion of doctors and therapists since I’ve been exploited in the past. (Litlove’s hospital experience also springs to mind as a good example of how medical practitioners can, perhaps unknowingly, be insensitive.) But part of me also wants to hang in there for a bit. If a lot of these feelings arise from my own projections (of previous insensitive males), then can I change the projections by working on them?

Lastly, if there are any clients out there who are wondering if they should confront their shrinks with their reservations, my advice is: Absolutely! Talking about the therapeutic relationship can be wonderfully liberating if it’s done in a helpful way.