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.

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17 Responses to For and against psychoanalysis

  1. litlove says:

    What a fascinating post, Pete! I confess I didn’t realise that there was such a divide between psychoanalysis and psychodynamic theories. I thought they were all siblings in the same family, if you see what I mean. I am all for an eclectic approach. One of the reasons I finished with my therapy was a niggling belief that my therapist was following his theories without really understanding which parts of them did not fit me at all. I also disliked it when he attempted to remove himself from our intereaction and insist he was simply a screen. The interest for me in the process is to have two subjectivities interacting with maximum self-awareness. Anything that puts the therapist in a position of invulnerable authority seems dodgy to me! But anyway, such an interesting debate and so good to have your thoughts on it.

    • Shelob 321 says:

      One thing I have noticed in therapy sessions is that what is asked is not always listened to or understood. It is as if the therapist does not realize the question is really much simpler than his various theories have taught him. Also I have found therapy sessions more interested in telling me how to behave (without any reasons being given). And as above, when the answer does not fit me, I am supposed to accept on authority what is said. I am a person who needs to be listened to in detail, not simply put in a slot!

      • Pete says:

        Hi Shelob. I did reply but am trying again. I completely agree that listening and understanding are much more important than giving advice. There’s no substitute for being understood and having your feelings respected. I also know from being on both sides of the therapy experience how difficult it can be. Sorry that you had a bad experience.

    • Pete says:

      Thanks Litlove. Yes, I think they are siblings in the same family but there is quite a lot of sibling rivalry! I also like a more intersubjective approach and am not that keen on therapists who hold themselves up as powerful authorities.

  2. I recently finished reading “What Disturbs the Blood” and I’m just glad that none of the methods debated involved injections, electricity, or chopping up the brain. Sometime ago I read that the most effective therapists arrived at a similarly eclectic approach regardless of where they started from.

    • Pete says:

      HI Lilian. That sounds very disturbing and I certainly wouldn’t recommend those treatments (although I have heard, much to my surprise, that electro-convulsive therapy helps with very bad depression). I think the trick with an eclectic approach is to know when to use what strategy. But it should also be the client that determines the treatment and not the other way round.

  3. smithereens says:

    Wow, thanks for the great post. I wasn’t aware of such heated debates.

    • Pete says:

      Thanks Smithereens. As these debates go, this one wasn’t terribly heated although I did feel sorry for Salkovskis and Wolpert since the audience were so firmly against them.

  4. litlove says:

    Oh and Pete, if you’re thinking of reading Lacan, umm, well, my advice would be to think twice. He is very theoretical and incredibly hard work. I would strongly recommend Winnicott as one of the great theorists whose work you can actually use day in day out. And as you saw on my post, Neville Symington is my latest deity – he writes particularly from the therapist’s point of view and is so very caring and practical. I’ve read a lot of therapists! And those two impress me most.

    • Pete says:

      Thanks for the good advice. I’d be very interested to read what Symington has to say. I see that he’s written a book about narcissism (always a good topic) and that he says that therapy can actually entrench narcissism rather than diffusing it. I’m putting him on my list right away.

  5. […] of stigma and politicking around this week. From the ongoing CBT-versus-everything else punch up (this time psychoanalysis fighting its corner) to Liverpool Council (in the UK) getting itself in trouble for suggesting (and I paraphrase) that […]

  6. I vote “1” for eclecticism. Though I primarily practice CBT, of course there are times when delving into deeper psychic processes, in particular attachment theory, are necessitated. But then, learning theory can pretty much account for most of what we’re talking about, it just feels more analytical when I hear myself referencing “projection” and other defense mechanisms. What I mostly don’t like about psychodynamic practitioners is the frequency with which they throw about such heavy, incriminating terminology about their patients. This one is a narcissist and that one is dependent and this one has oedipal impulses. So reductionistic and cynical. So little hope. And don’t get me started on the whole idea that there are no accidents. I had that one used against me multiple times during supervision with an “analyst.” Yawn.

    Great post!

    • Common factors? Never heard of them. says:

      I would argue that CBT is highly reductionist in its fixation with diagnoses and its tendency to over-simplify the human condition. As such, I find peculiar your criticism of reductionism in psychodynamic work.

  7. Ashana M says:

    My suspicion is that the practice of psychodynamic therapy has some elements in that are effective, but large portions of the theories behind it are of no relevance or value whatsoever.

  8. Angela Johnson says:

    I have been in psychoanalytic/ psychodynamic therapy for 7 years with a psychoanalyst and I have found it exhausting to the point of breakdowns and hospitalisations. Although I have had many breakthroughs doing it I really haven’t found it to be useful in real life. Also, my psychodynamic would always talk in pyschobabbble that I found very hard to understand. I broke up with him a week ago. He was an EXCELLENT shrink and I will love him forever but I feel like I need to work with someone else because I just feel shattered that he isn’t in my life anymore.

  9. Angela Johnson says:

    Analysis is great for understanding yourself but it doesn’t help much with developing social skills

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